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GOUT,

AND ITS RELATIONS TO DISEASES OF
THE LIVER AND KIDNEYS.

G O U T,

AND ITS RELATIONS TO DISEASES OF THE
LIVER AND KIDNEYS.

ROBSON ROOSE, M.D.,

Fellow of the Royal College of Physicians in Edinburgh.

LONDON:
H. K. LEWIS, 136, GOWER STREET.

1885.

(j <7 Ob

SIR WILLIAM W. GULL, BART., M.D. LOND., F.R.S.,

D.C.L. Oxon., LL.D. Cantab, and Edin.,

THIS WORK IS BY PERMISSION

AS A TOKEN OF GRATITUDE, ESTEEM, AND ADMIRATION,
BY

THE AUTHOR.

Digitized by the Internet Archive

in 2011 with funding from

Open Knowledge Commons and Harvard Medical School

http://www.archive.org/details/goutitsrelationsOOroos

PREFACE

The following pages contain the results at which I
have arrived after a somewhat extensive clinical ex-
perience of the gouty dyscrasia in its various forms.
While far from denying the influence of heredity and
other causes, I am fully convinced that functional
disorder of the liver underlies the majority of gouty
manifestations, and that the kidneys are only second-
arily implicated. If this view be correct, it would
seem to follow that the object of treatment should be
not merely the neutralisation of the materies moirbi
by means of alkalies, but, in an especial manner, the
restoration of the hepatic functions. How this is to
be effected, I have described at some length in the
chapter on treatment. All statements quoted from
other writers have been carefully criticised, and I
have endeavoured to make my book in every way a
record of my own observation and experience.

9, Regency Square, Brighton,
May, 1885.

CONTENTS.

CHAPTER I.

General Considerations with regard to Gout ; Theories
as to Nature, and Morbid Appearances.

Peculiarities of the Disease — Views as to Nature and Relations to
Diseases of Liver and Kidneys — Diathesis, Definition of — Meaning
of the term Gout — Cullen's Definitions and Classification — Vis-
ceral and especially Renal Symptoms — Theories and Facts to
explain Nature of Gout — Sodium Urate in the Blood — Other
Changes in the Blood — Condition of the Urine — Morbid appear-
ances in the Joints, Aorta, Heart, Lungs, and Kidneys ... 1-20

CHAPTER II.

Sources and Places of Origin of Uric Acid in the System.

Variations in quantity of Uric Acid under various circumstances — In
Disease — Influence of Acidity — Mode and Places of Origin of Uric
Acid in the Economy — Two Theories : (1) Formation in the
System, especially in the Liver ; (2) Formation in the Kidneys
alone — Experiments on Birds and Snakes — Conclusions to be
arrived at — Dr. Parkes' Views — Dr. Latham's Theory of Gout —
Relation of Uric Acid to Gout — Two Theories: (1) Retention of
Uric Acid in the Blood as a result of Defective Elimination by the
Kidneys ; (2) Uric Acid increased as a result of Sub-Oxidation or
otherwise — Consideration of first theory — Objections to it ... 21-39

CHAPTER III.

Theories as to the Nature of Gout.

Excessive Production of Uric Acid in Gout — Circumstances influencing
the Excess — Formation of Urea and Uric Acid by the Liver —

A 3

CONTENTS.

Functions of the Liver — Temperature of the Liver — Lithaemia due
to Hepatic Derangements — Symptoms of the Uric Acid Diathesis
— Frequent occurrence of temporary Albuminuria in Gouty Dys-
pepsia— Eczema as a Symptom of the Gouty Diathesis — Neurotic
Theories of Gout — Views held by Dr. Dyce Duckworth, Dr.
Meldon, Dr. E. Liveing, Sir J. Paget, Dr. Ord, and Dr. Latham
— The Author's Views 40-57

CHAPTER IV.

Causes of Gout.

Predisposing Causes — Heredity — The Acquired Form — Geographical
Distribution — Sex and Age — Climate and Season — Errors in Diet
— Excess of Albuminous Food — Want of Exercise — Dr. Carpenter
on Diet as a Cause of Gout — Other Alimentary Substances —
Starch, Sugar, and Fats — Acidity — Influence of Fermented
Liquors — Lead — Mental Influence — Depressing Agencies — Excit-
ing causes of Gouty Paroxysms ... ... ... ... 58-72

CHAPTER V.

Irregular Manifestations of Gout — Visceral and Cutaneous
Affections.

Irregular Gout — Suppressed Gout — Peculiarities of the Irregular Mani-
festations— Detection of Uric Acid in the Blood in these cases —
Visceral Gout — Functional and Organic Affections — Gouty
Diseases of the Throat and Stomach — Dr. M. Mackenzie's Cases
of Gouty Throat — Retrocedent Gout of the Stomach — Two Forms :
Spasmodic and Inflammatory — Dr. Buzzard on Probability of
mistaking Gastric Crises of Tabes for Gout of the Stomach —
Question of Metastasis— Experimental Production of the Pheno-
mena of the Uric Acid Diathesis — Gouty Affections of the Heart —
Retrocedent Gout — Condition of Heart in Fatal Cases — Fatty
Degeneration — Gouty Phlebitis — Gouty Affections of the Lungs :
Asthma and Bronchitis — Dr. Stokes' Views — Dr. Greenhow's
Cases — Gouty Affections of the Nervous System — Gout retrocedent
to the Brain — Neuralgia, Headache, &c, in Gouty Subjects —
Gouty Neuritis — Disturbances of the Sensorial Functions — Gout

CONTENTS.

and Eczema — Dr. Piffard's Views on the connection between
certain Skin Diseases and the Rheumic Diathesis ... 73-96

CHAPTER VI.

Hepatic and Renal Disorders connected with Gout.

Hepatic Congestion frequent in Gouty Subjects — Inflammation of the
Biliary Ducts, Jaundice, &c. — Gouty Cirrhosis of the Liver —
Question as to its Causation — Influence of other Substances besides
Alcohol — Dr. Budd's Views — Biliary Concretions in Gouty Subjects
— Renal Disorders due to Imperfect Assimilation and Hepatic
Derangement — Albuminuria as a Symptom — Question as to
Physiological Albuminuria — Dr. Senator's Views — Digestion-
Albuminuria — Influence of Albuminuria upon the Kidneys —
Question as to Indication of Renal Mischief when " Digestion -
Albuminuria " is observed — The " Gouty Kidney " properly so-
called, varieties of — Association of Infarctions of Urates with
Renal Cirrhosis — Symptoms of Gouty Kidney — Gravel, Calculus,
Bladder- Affections, and Diabetes in Gouty Subjects ... 97-119

CHAPTER VII.

The Treatment of Gout and of Various Disorders
connected with it.

The Treatment of the Gouty Diathesis — Evidence that the Gouty
Diathesis may be Modified or Removed — Objects to be aimed at
in the Treatment — Question of Diet for Gouty Subjects— Animal
Food — Drawbacks attending excessive use of Vegetable Food —
Quantity of Meat to be allowed — Other articles of Food — Acids to
be avoided — Farinaceous Food — Alcohol — Milk — Tea, Coffee, and
Cocoa — Articles of Diet suitable for Gouty Subjects — Question as
to Gelatine — Quantity of Food — Importance of Diet-Rules —
Printed Forms desirable — Production of Sense of Satiety to be
avoided — Exercise for Gouty Subjects — Horse Exercise — Walking
— Passive Movements — The Zander Method — Fresh Air — Good
Influence of Sea Air — Mountain Air — Condition of Liver and
Stomach — Action of Saline Purgatives — Various Mineral Purgative
Waters, Friedrirhshall, Pullna, &c. — Carlsbad Salts — Other

xii CONTENTS.

Purgatives and Hepatic Stimulants — Alkalies — Mineral Waters of
Bath, Buxton, Wildbad, Teplitz, Vichy, Baden, Wiesbaden, Aix-
la-Chapelle, and Aix-les-Bains — Efficacy of Water as a Drink for
Gouty Subjects — The simple Thermal Waters — Alkaline Waters —
Muriated Saline Waters — Turkish Baths — Avoidance of Excite-
ment and a proper amount of rest necessary for Gouty Subjects —
The Treatment of an Acute Attack of Gout — Purgatives —
Alkalies — Colchicum — Belladonna as a Local Application — Diet
and Regimen — Treatment during the intervals — Iodide of Potassium
— Alkalies — Mineral Waters — Guaiacum — Tonics as Iron, Quinine,
&c. — Local Treatment in Chronic Gout — Chalk-stones and Gouty
Ulcers — Treatment of Gouty Disorders of the Liver and Kidneys
and of Gouty Cutaneous Affections ... ... ... 120-149

AND ITS RELATIONS TO DISEASES Oh
THE LIVER AND KIDNEYS.

CHAPTER I.

GENERAL CONSIDERATIONS WITH REGARD TO GOUT ;

THEORIES AS TO NATURE, AND MORBID

APPEARANCES.

Peculiarities of the Disease— Views as to Nature and
Relations to Diseases of Liver and Kidneys — Diathesis,
Definition of — Meaning of the term Gout — Cullen's
Definitions and Classification — Visceral and especially
Renal Symptoms — Theories and Facts to explain nature
of Gout — Sodium Urate in the Blood — Other Changes
in the Blood — Condition of the Urine — Morbid appear-
ances in the Joints, Aorta, Heart, Lungs, and Kidneys.

GOUT is undoubtedly one of the most remarkable
and perplexing disorders with which the physician
has to deal. Wayward and capricious in its onset
and course, and astonishingly varied in the forms
which it assumes, its manifestations may at first sight
appear to be subject to no intelligible law. An acute
attack indeed is marked by a perfectly definite series
of phenomena, as regular in their development as

B

PECULIARITIES OE GOUT.

those of uncomplicated scarlatina. On the other
hand, the disease may be almost entirely latent, its
presence being revealed by obscure symptoms, slight
in degree, and evanescent in character, and often refer-
able to their true origin only when a decided family
proclivity, or the subsequent progress of the case,
serves to guide the diagnosis aright. Midway between
these forms are others in which the malady makes
itself felt either in the internal organs alone, or in
these alternately with the superficial parts. Thus,
whilst in certain instances the symptoms may be
indicative solely of functional disturbance or of
structural mischief in the kidney, liver, or stomach,
in others they alternate with external phenomena,
sUch as pain and swelling in one or more of the
joints. The study of an affection so complex, and,
if I may be allowed the expression, kaleidoscopic
in its character, is full of interest, but it obviously
presents considerable difficulty.

It is not my intention to discuss in detail the
ordinary symptoms of gout, for they are too well
known to need description. I shall only refer to
such of its features as are more immediately connected
with that theory of its pathology which I am anxious
to establish. My object in this little work is to place

DIATHESIS AND DEFINITION OF GOUT. 3

before the profession my views as to the nature of gout,
and more especially as to its relations to those dis-
orders of the liver and kidneys with which, according
to my experience, it is very often connected. I shall
also add a few words on those affections of the skin
which I believe to be due to the presence of the gouty
diathesis. I use the word "diathesis" to express "a
general tendency, in virtue of which an individual
becomes the subject of several local affections, similar
in their nature." I believe that gout is a disease of a
specific character, but capable of assuming widely
different forms, and of causing a vast number of
symptoms, disturbances, and complications, many of
which often remain inexplicable until an acute attack
furnishes the key to the diagnosis.

There can be no objection to the use of the word
"gout" to designate the disease. Its meaning is
well understood, and it is much to be preferred to
"podagra," "chiragra," &c, which serve only to
describe some of the local manifestations. The term
"gout," on the other hand, owed its origin to the
" humoral " view of the pathology of the disease, the
idea being that some morbid humour existed in the
blood, and was thrown out or distilled into the joints
" drop by drop." We shall presently see that this

B 2

4 CULLEN' S DEFINITIONS AND VARIETIES.

idea is the basis of that theory of the origin of the
disease which is most in accordance with well-ascer-
tained chemical and pathological facts.

If we wish to define the word "gout," and to classify
the various forms of the affection, we can scarcely do
better than adopt Cullen's language and arrangement.
Cullen tells us that gout is hereditary, coming on
without apparent external causes, but generally
preceded by an affection of the stomach ; that it
is characterised by pyrexia, by pain at some one of
the joints, generally at that of the great toe ; certainly
attacking by preference the articulations of the feet
and hands ; returning at intervals, and often alternating
with affections of the stomach or other internal parts.
Regular gout, Cullen defines as characterised by
considerable and violent inflammation of the joints,
continuing for several days, and receding gradually
with swelling, itching, and desquamation of the
affected part. His second variety is atonic gout,
in which there is debility of the stomach or of
some other internal part, either without the usual
inflammation of the joints, or with slight and transient
pain in them, often alternating with dyspepsia or
other symptoms of debility. In the third form,
retrocedent gout, the inflammation of the joints sud-

CLASSIFICATION OF VARIETIES.

denly disappears, but is soon followed by atony of the
stomach, or of some other internal part. In wander-
ing gout, there is inflammation of some internal part,
sometimes preceded by inflammation of the joints,
which quickly disappears. Cullen adds to these de-
scriptions the significant remark that gout is sometimes
accompanied by other diseases. This old nomen-
clature is really based on clinical observation, and
does not involve any theory as to the nature of the
disease. Cullen's opinion on this point, however, was
that gout is an affection of the nervous system.

Whatever form the attacks of gout may assume,
other symptoms are pretty certain to become de-
veloped during the course of the disorder, and
especially in the intervals between the attacks : of
these, hepatic derangements, dyspepsia, and gravel
are by far the most common. If, moreover, careful
inquiry be made into the history of a case of acute
gout, we almost always find that the attack has
been preceded by more or less distinct symptoms of
disorder of the liver or stomach, or of both of these
organs ; and this fact is of importance as regards the
etiology of the disease. There is another well-marked
characteristic of gout, viz., that in most cases the
attacks become more frequent year by year, without

6 THEORIES AS TO NATURE OF GOUT

diminishing in length ; the disease in many cases being
really continuous, but presenting irregular exacerba-
tions and remissions. This chronic stage generally
owes its origin to serious implication of the kidneys.

Three principal theories are still in vogue with
regard to the nature and origin of gout. According
to the first of these, gout is due to digestive anomalies,
causing the blood to become loaded with certain
morbid elements produced mainly in the stomach
and duodenum, and uniting in the blood with some
element of the bile which has been suffered to accu-
mulate through defective secretory action of the liver.
This view was supported by the late Dr. Todd,* who
admitted, however, that the condition is usually
associated with the lithic acid diathesis. The second
theory likewise assumes an impure state of blood, but
refers this condition principally to disturbance of the
renal function ; Dr. Garrod is the chief supporter of
this theory. The third view, that of Cullen, already
referred to, has lately been resuscitated. It assumes
that the nervous system is primarily at fault in cases
of gout.

Putting theories on one side for the present, let us

* " Practical Remarks on Gout, Rheumatic Fever, &c," p. 74.

SODIUM URATE IN THE BLOOD.

see what facts we possess which may serve to explain
the nature of gout. The most important fact in
connection with the pathogeny of gout is that uric
acid is found in the products of gouty inflammation,
and that the blood contains an increased amount of
this substance, which in both cases is combined with
soda. In health, only the most minute traces of uric
acid can be detected in the blood ; in gout, more than
one-sixth of a grain has been obtained from iooo
grains of serum. The process for its detection, as
devised by Dr. Garrod, is simple enough. One or two
fluid drachms of serum are put into a flattened glass
dish or capsule, three inches in diameter, and about
one-third of an inch in depth ; six minims of strong
acetic acid are added to each drachm of serum. The
fluids are well mixed, and a few fibres of linen are
introduced by means of a glass rod. The glass is
then set aside in a cool place until the serum is nearly
dry, and if uric acid be present it will crystallise in a
rhombic form on the threads, and will be easily re-
cognised under the microscope. The serum must be
fresh, for otherwise the uric acid will undergo decom-
position and become converted into oxalic acid and
urea. When blood cannot be obtained, the experi-
ment may be performed with the serum collected

8 CONDITION OF BLOOD AND SECRETIONS.

from a blister, provided that this latter has not been
applied to a point attacked by gouty inflammation,
inasmuch as inflammatory action causes the uric acid
to disappear from the affected part and its immediate
neighbourhood. In cases of chronic gout uric acid
can always be detected in the serum ; in acute gout it
may be absent between the attacks, but can always
be discovered shortly before these take place. It
must be borne in mind, however, that a similar excess
of uric acid in the blood is often found in cases of
chronic lead-poisoning and of certain diseases of the
kidney. Besides being found in the blood, uric acid
often exists in various secretions and fluids in gouty
cases. Thus it has been found in the cerebro-spinal
fluid ; in the effusion of pleurisy and pericarditis ; in
intestinal secretions ; in the discharges from cuta-
neous eruptions, and in the form of dust (sodium
urate) on the skin.

The blood presents other, though far less easily
discoverable differences in its chemical composition.
These are summed up by Charcot* as follows : —

I. In acute gout the proportion of the corpuscles
is not diminished (in this the disease differs

* " Lectures on Senile Diseases," New Syd. Soc. Trans, p. 55.

VARIOUS CHANGES IN BLOOD AND URINE. 9

remarkably from rheumatism) ; in chronic
gout there is considerable diminution and
more or less anaemia.

2. In acute gout the fibrin is increased ; the clots

are buffy.

3. In chronic gout the albumen of the blood is

diminished, if there be any disease of the
kidneys, and in such cases the blood contains
an increased amount of urea.

4. The alkalinity of the blood is diminished, a

condition which seems to favour the produc-
tion of chalky deposits.

5. The blood sometimes contains traces of oxalic

acid.

It is evident from the foregoing statements, that
while excess of uric acid is the most prominent and
characteristic change in the blood in gout, other
alterations, more or less important, are frequently
present.

The condition of the urine in gouty subjects exhibits
several points of interest which may be thus briefly
enumerated. During acute attacks the secretion is
scanty and high-coloured, but it contains less than
the normal quantity of uric acid ; perhaps only two
grains, instead of seven or eight, are excreted in the

SODIUM URATE IN THE TISSUES.

twenty-four hours. The blood-serum can easily be
shown to contain excess of uric acid. In the intervals
the condition of the urine varies, but there are often
deposits of urates and of crystalline uric acid. In
chronic gout the excretion of uric acid is for the most
part diminished, but from time to time there are
crystalline and amorphous deposits containing this
substance. Oxalate of lime is often found, tube-casts
and albumen are by no means rare, and sugar is
occasionally present.

Having thus briefly referred to the state of the blood
and urine, the morbid changes in gouty subjects
constitute the next point of importance. They are
well marked in severe and chronic cases, and are for
the most part the direct consequences of the excess of
uric acid in the blood. Certain tissues and organs are
the seat of deposits consisting of sodium urate, and a
careful study of these changes throws much light upon
the nature of the disease. The existence of the so-
called "chalk-stones" has been recognised from a
very early period, but they were regarded as associated
only with very severe cases of gout. A closer in-
vestigation has shown that even a very slight attack
leaves behind it marked changes in the structure of
the joints, and that these changes generally remain,

CHANGES IN THE JOINTS.

even in favourable cases, throughout life. The carti-
lages of the joints are the parts primarily involved ;
deposits of sodium urate form in them, and, as pointed
out by Charcot, occupy the superficial part, and are
situated either between the cells, or actually within
them. The first changes generally take place as far
as possible from the insertion of the synovial mem-
brane— a fact which Charcot explains by assuming
that the so-called non-vascular tissues are especially
liable to be the seat of these deposits. It may be
that urates are less soluble in lymph than in blood.
On the other hand, the articular surfaces of the bones
and the synovial membrane, being highly vascular,
are less liable to be thus invaded.

At a later period of the disease, a similar deposit is
found in the synovial membrane, and here the same
rule is observed, inasmuch as the less vascular
portions at the circumference are the first to be
affected. As the disease progresses, the ligaments,
the tendons, and the connective tissue surrounding
the joint are successively attacked. It very rarely
happens that deposits of this kind are found in the
substance of the bone itself, owing, it may be presumed,
to the marked vascularity of the osseous tissue. Even
where the surfaces of the cartilage are completely

12 CHANGES IN THE JOINTS AND OTHER PARTS.

encrusted, the neighbouring portion of bone is usually
free from any trace of uric acid. The bones of gouty
persons, however, frequently contain an increased
amount of fat and a diminished quantity of earthy
matter. The most important point in connection with
these deposits is, that they appear to avoid the
neighbourhood of the blood-vessels. The cartilage
of the ear is often thus affected, and in a few rare cases
which have been reported the nodules were visible in
this part alone, while on post-mortem examination
the ligaments and cartilages of many articulations
were found to be more or less thickly covered. In
still rarer cases no external deposits are discoverable
during life.

As is well known, the metatarso-phalangeal joint
of the great toe is the one most commonly affected.
Next to it in order of frequency come the fingers, and
then the knees and elbows ; other joints are liable
to suffer, but the morbid changes are very seldom
so severe as in those just enumerated. It not un-
frequently happens that the great toe is the only
joint attacked. Several reasons have been adduced
to account for this preference ; it has been supposed
that this joint, bearing, as it does, much of the weight
of the body, and often cramped by ill-fitting boots, is

MICROSCOPIC APPEARANCES OF GOUTY DEPOSITS. 13

peculiarly liable to injury, and is therefore a locus
minoris resistentice. This theory is supported by those
instances in which injuries to joints in gouty subjects
have been followed by the characteristic deposits. A
case has been reported to me by a friend, of an
extremely gouty subject who took very little exercise
save on horseback. In his case, during a long series
of years, the knees alone were affected. Similar
results of injuries to bones and joints often occur in
the course of syphilis.

This deposit of sodium urate is peculiar to gout,
and does not occur in any form of rheumatism. It is,
as Dr. Garrod points out, the cause and not the effect
of the inflammatory symptoms, for when these are
severe the urate undergoes alterations and is removed
from the neighbourhood of the affected part. The
deposit, examined with the naked eye, is found to
resemble plaster of Paris ; examined under the
microscope, it is seen to consist of minute crystalline
needles of sodium urate, often collected into stellate
tufts and bundles. As already stated, the deposit is
both intra-cellular and interstitial, that is, it occupies
the interior of the cells, and the interstices between
them. When layers of cartilage thus affected are
soaked for some hours in warm water, the deposit

i4 CHALK-STONES AND GOUTY ULCERS.

becomes completely dissolved, and the cartilage is
almost or quite normal in structure. Wherever the de-
posit is found, the microscopic appearances are similar
to those presented by the affected cartilage. If acetic
acid be added, rhomboidal crystals of uric acid will
appear. The tophi, or chalk-stones, often seen in the
neighbourhood of the joints, consist of sodium urate,
with a little urate and phosphate of calcium. They
differ entirely from the bony nodosities of chronic
articular rheumatism. Their most favourite seats are
the joints of the hands and feet and external ear.
After some time, the skin covering them often becomes
thin and brittle, and particles of chalk-like matter are
found to cover the surface. In some cases the chalk-
stones set up considerable irritation, and abscesses
form, which, on bursting, leave ulcers. The discharges
from such abscesses are milky and paste-like, and
consist of sodium urate, pus, and debris. The ulcers
are indolent ; the granulations are spongy, scanty, and
yellowish ; and the bases and edges are studded with
particles of mortar-like material. Such ulcers often
remain without change for long periods, and are apt
to re-open after cicatrization.

In order to complete this sketch of the morbid
anatomy of gout, allusion must be made to the

CHANGES IN HEART, LUNGS, AND KIDNEYS. 15

various lesions of internal organs, due to the exist-
ence of the gouty diathesis. Atheroma of the aorta
is not unfrequent in chronic cases, and sodium urate
has been found in the coats of the vessel. Fatty
degeneration of the cardiac walls, due to atheroma
of the coronary vessels, has also been noticed. It
is doubtful whether the valvular deposits frequently
found in the hearts of gouty subjects are really due to
gouty inflammation, inasmuch as they do not contain
sodium urate, but consist, as usual, of phosphate and
carbonate of lime. With regard to the lungs, sodium
urate has been found in the bronchial walls, and uric
acid has been detected in the expectoration in a case
of gouty bronchitis.

It is, however, in the kidneys of gouty subjects
that the most prominent and characteristic lesions
are often discoverable, and a close study of these
is especially important, as regards not only the
etiology, but also the prognosis and treatment of
the disease. Gouty nephritis, the so-called gouty
kidney, is often found in severe and chronic cases,
but a less serious affection not unfrequently compli-
cates the slighter manifestations and earlier stages
of the disease, and the lesions found in the kidneys
may therefore be divided into two classes.

1 6 GOUTY DEPOSITS IN THE KIDNEYS.

In the first class, the kidneys present deposits of
uric acid and sodium urate scattered throughout their
substance. These deposits are found in the cortical
portion, in the pyramids, and in the papillae, and
likewise in the calyces and pelvis. The substance
of the kidney is hyperasmic, and otherwise resembles
in appearance that of the first stage of chronic
interstitial nephritis. The changes may be regarded
as the results of gouty inflammation, affecting not
only the uriniferous tubules, but also the fibrous
structures of the organ, and accompanied by the
deposits of urates. Dr. Garrod's view, that the fibrous
structures of the kidney are sometimes involved before
the joints, is supported by those instances in which
severe pain in the back precedes and is relieved by
the appearance of swelling in the great toe. The
occurrence of temporary albuminuria is doubtless
sometimes due to imperfect metamorphosis of albu-
minous substances by the liver, and perhaps to
transient gouty inflammation of the kidneys. If,
however, the albumen is permanently present,
changes of a serious nature must have set in.

This question of albuminuria in connection with
gout will be especially discussed in a subsequent
chapter.

GOUTY DEPOSITS IN THE KIDNEYS. 17

In the second class of cases, the kidneys present
not only the infarctions above described, but in
addition marked alterations of structure correspond-
ing to those of chronic desquamative and interstitial
nephritis. The infarctions appear as whitish streaks in
the medullary substance, and the papillae present little
whitish points. The deposits are formed in and
obstruct the uriniferous tubules, and are also found in
the interstitial tissue. Under the microscope these
infarctions are seen to consist of crystalline needles
of sodium urate, and they are chemically identical
with the substance found in chalk-stones, and in the
incrustations covering the articular cartilages. The
structure of the kidney, moreover, presents marked
alterations. According to Charcot, there is at first
a tubular nephritis, of two different degrees. In the
first, the size of the kidney is unchanged, but the
cortical substance is thickened and yellowish in
colour. The Malpighian bodies are injected, and the
uriniferous tubules are filled with epithelium cells,
distended, opaque, and full of fatty or albuminoid
granules. In the second stage there is atrophy of
the cortical substance, and a granular condition of the
kidney generally.

The alterations above described affect principally

1 8 GOUTY CIRRHOSIS OF THE KIDNEYS.

the uriniferous tubules, but in the gouty kidney,
properly so called, there are likewise interstitial
changes of a cirrhotic character. Thus there is
thickening of the intertubular connective tissue and
proliferation of the nuclei ; the kidney becomes
harder and diminished in weight and volume. The
capsule is thickened and opaque, the surface is
wrinkled and nodulated, and the cortical substance
much reduced in quantity ; in some cases the
pyramids almost reach the surface of the organ.
The infarctions of sodium urate appear as whitish
streaks in the pyramidal portion. In some cases
of this character the kidney has been found to weigh
only two-and-a-half ounces.

Of the renal lesions just described the deposits
of sodium urate may be designated as altogether
peculiar to gout ; for they are seldom, if ever, found
in connection with any other disease. The other
appearances are often found in that form of Bright's
disease which is termed "cirrhosis" of the kidney.
The co-existence of the urate infarctions with the
contracted kidney frequently occurs in advanced
cases of gout, and indicates a very close relation
between the two diseases. There is also strong
evidence in favour of the view that the kidneys

GOUTY CHANGES IN THE KIDNEYS. 19

are often affected at a very early period, even after
a few moderate attacks have occurred. A granular
condition of the epithelium, with excess of oil globules,
and white streaks in the pyramids, constitute the
earliest changes, while crystals of sodium urate occupy
the intertubular fibrous structure and the tubules.
The changes may co-exist with a perfectly natural size
and weight of the kidneys, and with such a condition
of their structure as appears normal to the naked eye.
This fact has an important bearing upon the etiology
of gout, and upon the part which renal disease takes
in intensifying and perpetuating its manifestations.

Whether the kidneys simply excrete or really
secrete uric acid, disease of their tubular structure
must affect the amount of this substance eliminated
from the body, just as occurs in the case of urea.

In advanced stages the tubes become denuded
of epithelium and are shrivelled and wasted. The
Malpighian bodies are brought closer to each other
and appear to have increased in number. The coats
of the vessels, especially of the afferent arteries of
the tufts, are thickened or hypertrophied, and the
vessels themselves become tortuous. All these
changes still further impede the excretion of the
urinary constituents.

C 2

SODIUM URATE IN GOUT.

Sodium urate, having been thus shown to be the
materies morbi of gout, I shall, in the next chapter,
discuss the existing theories with regard to the source
and place of origin of uric acid.

CHAPTER II.

SOURCES AND PLACES OF ORIGIN OF URIC ACID IN
THE SYSTEM.

Variations in quantity of Uric Acid under various circum-
stances— In Disease — Influence of Acidity — Mode and
Places of Origin of Uric Acid in the Economy — Two
Theories : (i) Formation in the System, especially in
the Liver; (2) Formation in the Kidneys alone — Ex-
periments on Birds and Snakes — Conclusions to be
arrived at— Dr. Parkes' Views — Dr. Latham's Theory
of Gout — Relation of Uric Acid to Gout — Two
Theories : (i) Retention of Uric Acid in the Blood as
a result of Defective Elimination by the Kidneys ;
(2) Uric Acid increased as a result of Sub-Oxidation
or otherwise — consideration of first theory — objec-
tions to it.

The account given in the previous chapter of the
pathological appearances observed in gout clearly
shows that the deposition of sodium urate in the
cartilaginous structures of the joints is the fundamental
fact upon which all theories as to the nature of the
disease must be founded. The demonstration of an
excess of uric acid in the blood constituted an impor-
tant step towards the discovery of the cause of the

22 QUANTITY OF URIC ACID EXCRETED.

disease ; but the sources and origin of uric acid in the
system, even under normal circumstances, are still to
be reckoned among the obscure points of physiology.
It is therefore difficult to construct a complete and
satisfactory theory which will explain the excessive
production of this substance in disease. Before, how-
ever, entering upon the question of excessive produc-
tion, it seems desirable first to discuss the various
opinions now in vogue concerning the sources and
places of origin of uric acid in the human body.

Under ordinary circumstances a healthy man
excretes only 8 grains of uric acid (C5H4N403) per
diem. It exists in the urine partly free and partly
combined with the alkaline phosphates. The quantity
rises and falls with that of the urea ; the average pro-
portion between the two substances being I to 50.
Under conditions of abstinence from food, and when
only non-nitrogenous substances are taken, the quantity
excreted may fall as low as two or three grains ; on
the other hand, with a full animal diet it may rise as
high as 30 grains. It is, however, a matter of fact that
an excessive amount of uric acid is sometimes regu-
larly excreted by pale and impoverished persons living
on a diet poor in quality and not over-abundant.
Under such circumstances the excess may be sup-

VARIATIONS IN QUANTITY OF URIC ACID. 23

posed to be due to imperfect metabolism. As a
general rule, the variations in quantity are indepen-
dent of differences in age, sex, height, weight, or
temperature. Moderate exercise appears to cause a
slight diminution in the quantity ; prolonged or
violent exertion, on the other hand, produces an
opposite effect. A decided diminution has been
observed after copious draughts of water, and the
quantity is said to be diminished after the use of
alcohol, and after the administration of quinine in full
doses. Iodide of potassium, chloride of sodium and
caffein cause more or less diminution, though the
statements with regard to salt are somewhat conflict-
ing. The inhalation of oxygen is followed by rapid
diminution of the uric acid, or even by its total disap-
pearance from the urine. The administration of the
carbonates of soda and lithia has been thought to
exercise a very decided influence upon the excretion
of uric acid, inasmuch as urinary deposits composed
of this substance rapidly disappear during a course of
these drugs. It is, however, doubtful whether the
uric acid is really diminished in quantity, and it would
seem more probable that the disappearance of the
sediment when alkaline carbonates are taken is due to
the conversion of the acid phosphate of soda into a

24 URIC ACID IN VARIOUS DISEASES.

neutral salt, and a consequently diminished precipita-
tion of the uric acid. Besides this, some of the uric
acid would unite with the alkalies, and form urates
which are far more soluble than uric acid. The use
of mineral waters, containing the sulphate and car-
bonate of soda, with a little chloride of sodium, is
followed by a decided diminution of uric acid in the
urine.

The known variations in the quantity of uric acid
excreted in cases of disease are as follows : —

In febrile states of the system, e.g., in traumatic
fever, typhoid, small-pox, and acute rheumatism, the
quantity of uric acid rises and falls with that of the
urea. It is absolutely increased in those cases in
which the elevation of temperature is associated with
impediments to respiration, as occurs when such com-
plications as pneumonia, capillary bronchitis, pericar-
ditis, or pleuritic exudations are present. In cases
of disease in which the action of the diaphragm is
impeded from any cause, as in abdominal tumours,
ascites, &c, there is an increased amount of uric acid
in the urine. It would therefore appear that an
increased excretion of uric acid generally occurs
whenever there is decreased energy of the processes of
oxidation.

URIC ACID IN VARIOUS DISEASES. 25

In chronic gout, with deposits of urates in and
about the joints, there is, as we have seen, a much
diminished excretion of uric acid by the kidneys. In
some forms of chronic splenic tumour, a similar con-
dition is observed ; but in others, and notably in cases
of leucocythsemia, the quantity is often enormously
increased. In one reported case, the daily excretion
amounted to sixty grains. It may be that this in-
crease is due to increased production in the diseased
spleen, or to diminished oxidation in the system.

In anaemia and chlorosis, the uric acid is reduced
in quantity, unless there be dyspnoea, in which case an
increase is observed. In chronic affections of the
respiratory and circulatory organs, accompanied by
difficulty of breathing, and a consequent diminution
in the supply of oxygen, the uric acid is increased in
quantity. In carbonic oxide poisoning the proportion
of uric acid to urea has been observed to be as high as
1 to 27.

In chronic affections of the kidney, diabetes, and
polyuria, the uric acid is generally diminished in
quantity. In diseases of the liver there are consider-
able variations ; in cirrhosis the quantity of sodium
urate excreted is sometimes very high. Also in acute
congestive hepatic affections the quantity is much

26 URIC ACID AND ACIDITY OF THE URINE.

increased, but according to Dr. G. Harley,* it is
diminished in fatal permanent jaundice. In various
forms of indigestion, and in cases of diminished
cutaneous activity, sediments of urates are of common
occurrence in the urine on cooling, but their precipita-
tion must not be regarded as necessarily indicative of
the presence of an unusual amount of uric acid. There
is, moreover, as pointed out by Dr. Bence Jones, no
relation "between the acidity of the urine and the
absolute amount of uric acid which it may contain ; for
in the urine which is most acid, and which deposits the
largest uric acid sediment, very little uric acid may
really exist ; whilst that which contains most uric acid
may hold it in perfect solution, and may have but a
feeble acid reaction." The presence of some other
acid is doubtless the main cause of the deposit of uric
acid sediments, for the addition of any acid to the
healthy secretion passed soon after food is always
sufficient to produce it. The temperature of the fluid
also influences the precipitation ; if this be high, a
larger amount of uric acid is held in solution than
under opposite conditions. Concentration of the
liquid, on the other hand, favours the deposition of
the uric acid sediment, for it augments the proportion
-•* " Diseases of the Liver," p. 761.

MODE AND PLACE OF ORIGIN OF URIC ACID. 27

of the urate to the water, and intensifies the acid
reaction. " Thus the uric acid sediment may be re-
garded as dependent upon three concurrent conditions,
(1) decrease of temperature, (2) increased proportion
of uric acid compound to the water, positively or
relatively, (3) increased acidity of the urine."* It is
therefore evident that a copious precipitate either of
uric acid or urates is no real indication of the quantity
of uric acid actually present, which can be determined
only by analysis.

Having thus described the principal variations
occurring in the quantity of uric acid eliminated, the
next subjects for consideration are the mode and
place of origin in the human body of this important
constituent of the urine.

Uric acid is one of the results of the metabolic
processes which are constantly going on during life.
Of the four principal elements, carbon, hydrogen,
oxygen, and nitrogen, of which the body is composed,
and which constitute the bulk of the excrementitious
materials, the nitrogen is eliminated almost exclu-
sively by the kidneys, in the forms of urea and
uric acid. These two substances differ in one very

* See Carpenter's " Principles of Human Physiology," ninth edition,
p. 476.

28 THEORIES AS TO PL A CE OF ORIGIN OF URIC A CID.

important respect, viz., as regards their solubility,
urea being very soluble in water and in the fluids of
the body ; uric acid, on the other hand, requiring for
its solution about eight thousand times its weight of
distilled water at the temperature of the blood. Uric
acid unites with various bases, and the salts thus
formed are more soluble than the acid itself. They
are, however, much less soluble than many other
substances, and they and uric acid readily crystallise
out from their solutions. It is owing to their insolu-
bility and their proneness to reassume the solid form,
that uric acid and its salts, though existing in such
small amounts in the urinary excretion, so frequently
give rise to disease. The fact that the urine of birds
and of reptiles is composed almost entirely of uric
acid is one of considerable interest as regards the
relations of this substance to urea.

Two principal theories have been advanced with
regard to the place of origin of uric acid in the
animal economy. According to the first of these,
uric acid is formed in the system in general, during
the changes which are constantly going on. Some
authorities believe that it is produced mainly in the
spleen, liver, and lymphatic glands ; others think that
the connective tissue is the principal seat of origin.

THEORIES AS TO PLACE OF ORIGIN OF URIC ACID. 29

It is certainly found in considerable quantities in
the liver and spleen, but only slight traces are dis-
coverable in the muscles. After its formation it
passes into the blood, and is rapidly eliminated by
the kidneys. According to this view, the kidneys
merely serve as a filter through which the uric acid
passes.*

According to the second theory, uric acid is pro-
duced exclusively in the kidneys, and does not exist
preformed in the blood. The epithelial cells of the
uriniferous tubules are credited with the power of
selecting from the blood the necessary materials, and
of converting them into uric acid. The fact that uric
acid has been repeatedly discovered in the blood
appears to militate against this theory ; but its pre-
sence is explained by assuming that it is absorbed
from the cells of the kidney.

In reference to this important point, it may be
useful to refer to some experiments in which the
ureters of certain birds were occluded by means of
ligatures. As is well known, the urine of birds
consists to a very great extent of uric acid, but this

* See Dr. Garrod's Lumleian Lectures on " Uric Acid and its rela-
tion to Renal Calculi and Gravel," Medical Times and Gazette, 1883,
vol. i.

30 THEORIES AS TO PLACE OF ORIGIN OF URIC ACID.

substance has not hitherto been detected in the blood
of these animals. After the ligature of the ureters,
incrustations of urates were found throughout the
kidney (the Malpighian corpuscles alone excepted), on
all the serous membranes, on the mucous membrane
of the tongue, oesophagus, and bowels, in the spleen,
liver, gall-bladder, lungs, joints, muscles, bones, and
lymphatic vessels ; only the brain and the blood
remained free. The same results were obtained after
ligature of the ureters in snakes ; but after removal
of the kidneys in these creatures, deposits of urates
were found only upon the edges of the wound, and in
the places which the kidneys originally occupied.
Inasmuch as when the kidneys were suffered to
remain, and the ureters tied, copious deposits were
found, but when these organs were removed, the
deposits were almost absent, it might be inferred that
uric acid is produced, in these animals at least,
exclusively by the kidneys.

Several objections may, however, be raised against
this interpretation of these experiments. If uric acid
were formed in the kidneys alone we should not
expect to find it in the cicatrices left after the
removal of these organs. Moreover, in the experi-
ments in which the ureters were tied, with a copious

THEORIES AS TO PLACE OF ORIGIN OF URIC ACID. 31

deposit of urates in many organs and tissues as the
result, we should expect to find uric acid in the
blood, if this substance were formed in the kidneys,
and carried by the circulation to the parts in which
the deposits occur. It is well known that the tubuli
uriniferi of serpents generally contain large deposits of
urates, and it is quite possible that the incrustations
found in various organs after ligature of the ureters
may have resulted from the absorption of the deposits
originally contained in the kidneys. Moreover, the
discovery of urates in so many organs while the blood
was free from them would seem to prove that the
uric acid was actually formed in the organ in which
it was found.

Other arguments might be adduced to show that
the formation of uric acid takes place throughout the
body. It may be that a minute quantity is produced
in the kidneys as a result of the active changes going
on in these organs ; but the single fact that uric acid
can be discovered in the connective tissue and in
various organs in a state of health, is conclusive
evidence that its production takes place throughout
the body generally. A similar source of origin may
be claimed for urea, which is most probably formed in
all the glandular cells of the body, but especially in

32 THEORIES AS TO PLACE OF ORIGIN OF URIC A CID,

the liver. According to Dr. Parkes,* in cases of
hepatitis and hepatic abscess, when suppuration was
excessive, the urea was found to be lessened in a degree
proportionate to the extent to which the secreting
structure was destroyed by the abscess. When the
liver was not suppurating, but actively congested and
enlarged, the amount of urea and uric acid seemed to
be increased. With regard to the relations between
these two substances, Dr. Parkes' opinion was that uric
acid is not an anterior stage of urea, but has an
independent origin of its own in some cells which are
especially endowed with the power to form it. From
his observations of several cases of enlarged spleen,
attended by a nearly four-fold excretion of uric
acid, he was led to suggest that the spleen may
perhaps produce more uric acid than urea. Some
physiologists think that urea is produced in the liver,
and results from the disintegration of the haemoglobin
of the effete red blood-corpuscles. Dr. G. Harleyf
thinks that urea is not a special product of the liver,
but the ultimate product of all tissue disintegration.
He admits, however, that in acute yellow atrophy of

* Lancet, 1 87 1, vol. i, p. 467.

f "Diseases of the Liver," p. 761.

DR. LATHAM'S THEORY. 33

the liver, the amount of urea eliminated diminishes in
proportion to the destruction of the liver-tissue.

A theory recently advanced by Dr. P. W. Latham*
with regard to the formation of uric acid, is thought
by him to meet several difficulties connected with other
views. Dr. Latham suggests that urea is formed from
the glycocine (glycine) of the bile. After this fluid
has served its purpose in digestion, the glycocine and
taurine are returned into the blood, and are carried
by the portal vein into the liver. In this organ these
substances, together with leucine and tyrosine, are
converted into urea ; but if from any cause the meta-
bolism of glycocine is interrupted while taurine and
leucine, &c, still undergo the normal changes, the
liver would contain both urea and glycocine. Dr.
Latham further assumes that the conjugation of these
substances by the gland would result in the production
of certain compounds, one of which on arriving at the
kidneys is, in these organs, conjugated with urea and
is excreted as ammonium urate.

This substance is very slightly soluble, one part
requiring as much as 2,400 parts of water at ioo°
Fahr. for solution. In consequence of this property a

* " On the Formation of Uric Acid in Animals and its relation to
Gout and Gravel."

D

34 DR. LATHAM'S THEORY.

certain portion may escape excretion and remain in
the blood — " overflow, as it were, and so pass on into
the circulation." In this fluid the ammonium salt
meeting with the soda would be converted into
sodium urate, the form in which it is deposited in and
around gouty joints. Dr. Latham concludes that the
appearance of uric acid in the secretion, is the result
of the imperfect metabolism of glycocine into urea,
whether that glycocine be derived from the bile
poured out into the duodenum or formed elsewhere in
the body. That it is from the bile is made some-
what probable from the fact that in the carnivora
whose urine contains little or no uric acid, the bile
contains no glycocholic, but only taurocholic acid,
and therefore no glycocine.

According to this view the imperfect metabolism of
glycocine is the primary and essential defect in gout
and gravel, and therefore functional disorder of the
liver is considered to take a prominent share in the
production of these disorders. Dr. Latham, however,
thinks that some change in the nervous system is the
most important factor in their etiology, such change
being either hereditary or acquired, and being situated
in the medulla oblongata, spinal cord, or both. I shall
have occasion to refer again to this theory in a sub-

DR. GARROD' S THEORY OF GOUT. 35

sequent chapter. The adoption of Dr. Latham's view
as to the production of urea involves the acceptance
of another and, as I think, an untenable theory, viz.,
that the formation of uric acid takes place in the
kidneys. Moreover, our knowledge of the metabolic
processes which go on in the organism is far too im-
perfect to allow us to assume that they are always
identical with changes which can be produced in the
laboratory.

The question as to the relation of uric acid to gout
will now be discussed, and I proceed to inquire whether
the disease is due mainly to retention of uric acid in
the system, or whether its primary cause is an m-
creased formation of this substance, as a result of
suboxidation of the tissues or otherwise.

The theory of the retention of the uric acid has of
late years been upheld by several observers, and
notably by Dr. Garrod.* Whichever theory be adopted
with regard to the origin of the uric acid, it is assumed
that in gout the excretory power of the kidneys is de-
fective as regards this constituent, though not as regards

* " A Treatise on Gout and Rheumatic Gout," third edition, p. 280.
Dr. Garrod says : " The imperfection in the eliminating power of the
kidneys sometimes appears to be the chief, if not the only cause of the
impurity of the blood." Dr. Garrod of course allows that increased
formation of uric acid plays a certain part in the production of gout.

D 2

36 RELATION OF URIC ACID TO GOUT

the urea and other substances. As a result of this
defective capacity of the kidneys, the uric acid accu-
mulates in the blood, and the prodromal symptoms of
gout are likely to become manifest. If the patient's
habits of life are such as to cause an increased pro-
duction of uric acid, an attack of gout will sooner or
later take place, and the disease will then pursue its
course with more or less regularity. According to
this theory, a functional affection of the kidney is the
true pathogenetic cause of gout. The experiments in
which the ureters of fowls and geese were tied, and
the operation was followed by deposits of sodium
urate in the joints, kidneys, and other viscera, have
been thought to support this view.

There are, however, many objections to this theory.
Gouty deposits do not necessarily take place in
connection with those diseases of the urinary organs
which are attended with a much diminished secretion
of urine. Moreover, gout often occurs in individuals
whose kidneys are to all appearances healthy, but
whose blood can be shown to contain an excess of
uric acid. If the urine be examined in the early
stages of gout, there is, as a general rule, no evidence
of any renal affection. It is quite true that on post-
mortem examination, the kidneys of gouty subjects

RELATION OF URIC ACID TO GOUT n

are often found to contain uric acid infarctions and
to present other morbid appearances, but these are
the consequences and not the causes of the gouty
dyscrasia. It may readily be conceived that the
irritation, often repeated or almost continuous, which
deposits of urates in the uriniferous tubules must
sooner or later set up, will give rise to serious changes
in the renal tissue, and the deposits which occur in
the interstitial tissue of the kidneys may be regarded
as the result of an attack of gout localised in these
organs. Persons who have never had any attacks of
gout, but whose urine often contains a deposit of uric
acid, are especially prone to suffer from inflammation
of the kidneys, and the relationship between gout and
uric acid deposits is based upon the fact that the uric
acid dyscrasia is common to both conditions.

Uric acid deposits and gout are frequently asso-
ciated in the same subjects, but cases sometimes
occur in which there are severe paroxysms of gout,
but no marked deposits of uric acid in the urine.
Under such circumstances neither albumen nor casts
are likely to occur. Such patients are, however, very
liable to renal inflammation, and when this occurs
there will be an increase of uric acid in the blood
and a diminished amount in the urine. If the mere

S8 DELATION OF URIC ACID TO GOUT.

occlusion of the tubules could give rise to gout, or if
the excess of uric acid in the tissues of gouty persons
were the consequence of its retention in the kidneys,
the disease would be of far more frequent occurrence,
and even infants would be liable to gouty deposits,
inasmuch as Virchow has shown that the kidneys of
new-born children frequently contain uric acid infarc-
tions. In addition to this, it is well known that many
persons suffer more or less from gravel during their
whole life, but are quite free from attacks of gout.
Some members of a gouty family exhibit all the
symptoms of the disease ; others suffer only from
gravel. It can easily be understood that an affection
of the kidneys which is accompanied by a lessened
excretion of urinary constituents will tend to increase
the frequency and severity of the gouty attacks. So
long as the kidneys remain sound, a rapid excretion
prevents undue accumulation.

The experiments above referred to in which ligature
of the ureters in geese and chickens was followed by
deposits of urates in and upon various organs will
scarcely help us to explain the phenomena of gout.
If the human organism produced as much uric acid
as that of birds, and if the flow of urine through the
ureters were absolutely prevented so that no more

RELATION OF URIC ACID TO GOUT. 39

could possibly be removed by the kidneys, it is quite
conceivable that the uric acid would be deposited in
and upon all organs of the body adapted for its re-
tention. There is, however, a very decided difference
between such deposits, and those of gout occurring
in an individual whose urine is free to escape.

The theory that in gout the uric acid excreting
function of the kidney is defective, rests upon a pure
hypothesis, and could be accepted only if no more
suitable theory could be discovered. Even those who
support it admit that it accounts only for the pro-
dromal symptoms of gout, and they allow that an
increased production of uric acid is necessary for the
full development of the disease. Such increased pro-
duction will form the next point for consideration.

4o

CHAPTER III.

THEORIES AS TO THE NATURE OF GOUT.

Excessive Production of Uric Acid in Gout — Circumstances
influencing the excess — formation of urea and uric
Acid by the Liver — Functions of the Liver — Tempera-
ture of the Liver — Lith^emia due to Hepatic Derange-
ments— Symptoms of the Uric Acid Diathesis — Frequent
occurrence of temporary Albuminuria in Gouty
Dyspepsia — Eczema as a Symptom of the Gouty
Diathesis — Neurotic Theories of Gout — Views held by
Dr. Dyce Duckworth, Dr. Meldon, Dr. E. Liveing, Sir
J. Paget, Dr. Ord, and Dr. Latham — The Author's
Views.

TOWARDS the close of the preceding chapter I en-
deavoured to show that defective diminution of uric
acid is not sufficient to account for its undue accumu-
lation in the blood in cases of gout. I now proceed
to discuss another theory, viz., that of excessive pro-
duction of uric acid in the system, a condition which
is liable to occur under the following circumstances : —
In the first place, albuminous constituents may be
supplied in excess, and the surplus fails to become
properly oxidized. In the second, the oxidizing pro-

EXCESSIVE PRODUCTION OF URIC ACID. 41

cesses are imperfectly performed ; though the supply
of those constituents may be no more than is fairly
proportioned to the normal wants of the organism.
There is also a third class, in which not only are the
oxidizing processes far below the normal standard,
but the supply is manifestly in excess of the require-
ments. Under all these conditions the blood is liable
to become surcharged with imperfectly oxidized con-
stituents, of which uric acid is, for our present pur-
poses, the most important.

In the healthy organism by far the larger part of
the nitrogenous excreta appears as urea, which is more
highly oxidized than uric acid. Whether the entire
amount of urea which is eliminated from the system
results from the oxidation of this latter substance —
that is, whether uric acid forms a necessary stage in
the production of the urea — is a question which must
be answered in the negative. It is possible that uric
acid may be only one of several substances, out of
which urea is formed ; and in a healthy organism its
production may be the result of changes slightly
divergent from those concerned in the formation of
urea. It has been already stated that in all proba-
bility several tissues of the body participate in the
production of these substances, but there is strong

42 FUNCTIONS OF THE LIVER.

evidence in favour of the view that the liver is the
principal seat of their origin.

Up to within quite recent times the secretion of
bile was thought to constitute the principal, if not the
only, function of the liver ; though it would appear
that the earliest writers on medicine had far more
extended views as to the work performed by this
organ. It now seems clear that these old views de-
serve to be revived, and that the liver must be credited
with the discharge of at least three functions, viz.: (i)
the secretion of bile, (2) the formation of glycogen,
and (3) the destruction of albuminous matters derived
from the food and textures, and the formation of urea
and uric acid. It is with this third function that an
endeavour to trace the origin of gout is closely con-
cerned, and it is to the writings of the late Dr. Mur-
chison that the profession is especially indebted for a
clear exposition of the present state of knowledge on
this subject,* and for the inferences to be deduced
therefrom. His observations show that the liver is
largely concerned in the formation of the nitrogenous
matters which are eliminated by the kidneys. Some
evidence in favour of this theory has been adduced in

* Murchison, " Functional Derangements of the Liver. " Second
edition, 1879.

TEMPERATURE OF THE LIVER. 43

preceding pages, but there are other facts which
deserve attention. Deposits of uric acid and urates,
and an imperfect formation of urea are frequent signs
of functional as well as of organic affections of the
liver ; while there is experimental evidence of the
existence and formation of urea in this organ.

Another fact, referred to by Dr. Murchison, has an
important bearing on the subject of the hepatic func-
tions. It appears from Bernard's experiments that
the temperature of the healthy liver reaches 1040, or
even 1060. In dogs, the temperature of the blood in
the hepatic veins is much higher than that of the
portal vein, and the temperature of the upper part of
the vena cava is higher than that of any other part of
the body. The active chemical changes going on in
the liver are the probable cause of this elevation of
temperature, and this view is further supported by the
fact that in diseases of the liver the temperature is
often lower than normal, and that after the common
duct has been tied in animals there is no longer any
difference in temperature between the blood of the
portal and that of the hepatic vein.

If this view of the function of the liver be correct,
it is easy to understand how the condition termed
lithcemici) in which there is an excessive amount of

44 LITHMMIA FROM HEPATIC DERANGEMENT.

uric acid in the blood, may often depend upon de-
rangement of the liver, and therefore that the gouty
dyscrasia may have a similar causation. If there be
an imperfect transformation of albuminous matters,
with the production of uric acid instead of urea as a
consequence, we have at least one of the factors neces-
sary for the development of gout. The most common
cause of such imperfect transformation is an excess of
supply, combined (as it very often is) with deficient
action of the assimilating organs. It is well known
that an occasional deposit of urates in the urine is a
common result of over-indulgence at the table, and is
of no serious significance. When, however, such a
deposit is constantly or even frequently noticed, it is
of more or less grave import. Patients are apt to
think that the kidneys are "out of order," but in point
of fact it is not these organs, but the liver, which is
generally in fault ; and this distinction is one of para-
mount importance as regards the treatment, whether
curative or prophylactic, of such cases.

When these deposits are of constant occurrence,
the uric acid diathesis may be said to have become
established ; and in the majority of cases other
symptoms, perhaps noticed occasionally before, soon
become troublesome. There is more or less dyspepsia,

SYMPTOMS OF LITHJE.MIA. 45

as evidenced by flatulence, distension, and feelings of
uneasiness, or even severe pain, in the stomach and
duodenum. There is often nausea and either pyrosis
or acid eructations, in many cases there is a bitter
taste in the mouth, the tongue is dry and furred, the
bowels are irregular and generally constipated, the
liver is somewhat enlarged and tender on palpation,
the skin sometimes has a slightly jaundiced hue.
Palpitation of the heart and shortness of breath,
aggravated by exertion, are often complained of, and
a short dry cough is sometimes very troublesome.*
Symptoms of derangement of the nervous system are
almost always superadded. The temper becomes irri-
table and the spirits are depressed. The patient feels
uneasy and restless, or else there is lassitude, drowsi-
ness (especially after food), headache, and inability
for mental exertion. The sleep is broken and
unrefreshing. Noises in the ears and vertigo are
sometimes very troublesome and alarming. Hypo-
chondriasis is not unfrequent, and in women hysterical
symptoms may occur. In some cases frequent attacks

* Dr. Woakes (on "Post-Nasal Catarrh") has described many of the
symptoms of the uric acid diathesis as those of " the premonitory stage
of catarrh," and has explained in a very lucid manner the decided
predisposition towards taking cold evinced by many subjects of this
diathesis.

46 ALB UMINURIA IN GO UTY D YS PEPS I A .

of migraine, or of other forms of neuralgia, are
prominent symptoms ; in others, the small joints are
painful from time to time, but there is no decided
attack of gout. Pains in the heels and painful sensa-
tions of burning and tingling in the feet are sometimes
present and cause great annoyance.

It is obvious that all these symptoms are connected
with some peculiar condition of the system at large.
They are liable to periodical exacerbations, and they
are invariably aggravated by errors of diet. A little
beer or a glass or two of champagne will often cause
twinges in the knuckles, burning sensations in the
palms and soles, or even more decided manifestations
in these subjects.

Cases presenting many of the above symptoms,
variously combined, often come before me in practice,
and I never fail to examine the urine, which, in not a
few instances, I find to contain a distinct quantity of
albumen, without tube-casts. In a succeeding chapter
1 shall endeavour to explain this appearance ; for the
present it will be sufficient to say that I do not regard
the albuminuria in these cases as necessarily indicative
of pathological changes within the kidneys. The
urine is likewise scanty, generally high-coloured, and
abnormally acid ; after standing, it deposits an abun-

ECZEMA IN GOUTY SUBJECTS. 4 7

dance of urates and uric acid. Oxalate of lime is often
present. Precipitation of urates sometimes takes place
within the bladder, and in that case the urine is more
or less turbid when passed.

In a majority of cases the attack of articular in-
flammation is preceded by many of these symptoms,
and appears to follow them directly ; while in some
decidedly gouty persons no pother signs of gout than
those which characterise the uric acid diathesis
occur at any period of life. It may be said that in
these latter cases the gouty phase is never reached.
It is worthy of remark that some patients who suffer
from aggravated dyspepsia, and from gout, find them-
selves very much better than usual, as regards the
dyspeptic symptoms, for some little time before the
acute attack.

There is one other symptom which I must not fail
to mention. In many of my patients presenting the
symptoms of gouty dyspepsia, I have noticed the
occurrence of eczema, which appeared to alternate
with the gouty symptoms, inasmuch as it increased in
severity as the latter were relieved by the treatment.
The dyspeptic symptoms can be removed by very
careful attention to diet and appropriate medicines,
and, if due care be taken, they will not necessarily

48 NEUROTIC THEORIES OF GOUT.

recur. The patient, however, is still liable to attacks
of eczema, especially in the spring of the year, and
the complaint, in the absence of further treatment,
tends to become almost continuous. I shall have
more to say on the connection between eczema and
gout in a subsequent chapter.

An attempt to explain the nature of gout would
obviously be imperfect without taking into conside-
ration the evidence in favour of the neurotic origin
of the disease. By some authorities gout is regarded
as a disorder of the nervous system, that is, as
a tropho-neurosis — a view which has recently been
advocated by Dr. Dyce Duckworth.* This would
appear to be a convenient place for an account of the
arguments brought forward by him and other writers
in support of this theory.

Dr. Duckworth admits that it is impossible to
resist the evidence in favour of the direct connection
between the excess of uric acid in the blood and
the manifestations of gout, and that whatever views
be entertained as to the whole of the pathogeny of
this disease, the facts discovered by Dr. Garrod cannot
be set aside. The question, however, is whether the
theory of the excess of uric acid being the cause
* British Medical Journal, March 26, 1881.

NEUROTIC THEORIES OF GOUT. 49

of gout is sufficient to account for all the phenomena.
Cullen, as already mentioned, regarded gout as mani-
festly an affection of the nervous system, and asserted
that gout is more indicative of nervous disorder than
any other pyrexia. Stahl, however, was the first to
advocate the neurotic theory of gout, and Cullen
adopted his views.

Diseases belonging to the neurotic type may be
either primary or central, or may be secondary or
induced, and it is alleged that gout presents not a
few of the characteristics peculiar to the neuroses, e.g.,
heredity, the periodicity of the attacks, and subjection
of the disease to the law of alternation. Primary gout
is regarded as a diathetic neurosis, but a difficulty
arises in accounting for cases of gout occurring in the
absence of any neurotic taint. It is assumed that, at
least in some of these, a condition of lithsemia and
hyperinosis is set up as a result of high living, &c,
and that the consequent dyscrasia of the blood reacts
upon the nervous centres ; in other words, that a
secondary affection of some nerve-centre occurs in
consequence of the altered state of the blood, and
thus the order and special phenomena of the gouty
attack become developed. The fact that joint-
affections are occasionally witnessed in the course of

E

SO NEUROTIC THEORIES OF GOUT.

diseases of the cord and brain is also adduced as a
strong argument in favour of this theory ; and the
gouty arthritis is supposed to be connected with these
affections. A trophic centre for joints is assumed to
exist near the roots of the vagus in the medulla
oblongata.

In addition to such features as heredity and
periodicity, gout is considered to present many
other analogies with disorders of the nervous system.
The sudden supervention of the attacks ; the pre-
ceding sensations of ease and comfort so often
experienced ; the time of the occurrence of the
attack<^OHhM*ir^rj3^ysmal character; the con-
neown of the disease'^with other well-recognised
neuroses 'j'and the fact that the same causes are liable
to excite .attacks, have all.-oeen cited as evidences of
the close^eia-tion-whichT exists between gout and the
nervous system. The remarkable connection between
gout and diabetes is also adduced ; it being a well-
recognised fact that the two diseases sometimes
alternate, and that members of gouty families are
prone to suffer from diabetes. It is also claimed that
this theory of the origin of gout serves to explain
the effect of colchicum — a drug which has a powerful
action upon the nervous system.

NEUROTIC THEORIES OF GOUT. 51

Dr. Meldon,* of Dublin, has long advocated what
may be termed a neuro-humoral theory. He admits
that uric acid and soda must exist in the blood before
the disease can be produced, but is convinced that the
presence of these substances is not the sole cause of
gout. His view is that there must be depression of
the nervous system to cause an attack of gout — such
depression bringing about the union between uric
acid and soda so as to form the urate of soda.
According to this theory, nervous force when in a
normal condition keeps these two substances separate
and in a fluid state, and in a condition fit for elimina-
tion by the skin, kidneys, and bowels. When the
nervous influence is lessened, the uric acid and soda
unite in the tissues most removed from the blood and
circulation. The irritation and inflammation excite
the nervous system to increased energy, and the
disease for the time is arrested. One objection to
this theory is constituted by the fact that urate of
sodium is far more soluble than uric acid, and therefore
more easily eliminable by the kidneys.

Dr. E. Liveing,f in his classical work on Megrim,

* " Gout, Rheumatism, and Rheumatic Gout," 1872 ; and British
Medical Journal, vol. i, 1 88 1, p. 466.

f " Megrim, Sick-headache, and some Allied Disorders : A Con-
tribution to the Pathology of Nerve-Storms," 1873, p. 404.

E 2

52 NEUROTIC THEORIES OF GOUT.

is much inclined to assent to the view that gout in its
various forms is the manifestation of a disorder which
has its primary seat in the nervous system itself; and
he lays great stress on the connection which may
often be traced between gout and such disorders as
"megrim, asthma, angina pectoris, gastralgic parox-
ysms, and certain forms of transient mental derange-
ment." Sir James Paget expresses a somewhat
more guarded opinion with regard to the part
played by the nervous system in the causation of
gout.* He says : " Disturbance in the nervous system
in some form and part may be regarded as a factor in
every case of gout. There are reasons enough for
thinking that changes in the nervous centres deter-
mine the locality of each gouty process, while changes
in the relations of the blood and tissues determine
its method and effects ; and that thus we may explain
the symmetries of disease in gout, sometimes bilateral,
sometimes antero-posterior, and thus its metastases.
But these changes are a part of the pathology cf gout
which is not yet clinical."

According to another theory, proposed by Dr. Ord,f
the part played by the nervous system in this disorder

* " Clinical Lectures and Essays," 1879, p. 382.
f " St. Thomas's Hospital Reports," 1872.

NEUROTIC THEORIES OF GOUT. 53

is held to be the propagation of gouty inflammation
from part to part. It is also considered that there are
evidences of the direct action of the nervous system
in the production of the attacks. When the gouty
diathesis exists, any sudden excitement of the nervous
system is capable of producing gouty inflammation in a
violent form, and in several parts at once. As to the
nature of gout, Dr. Ord's views are that the disease is
a mode of decay of the whole system ; that the deposit
of urates is the result of local or general disintegration,
the local inflammation not necessarily depending upon
such deposit, but often set up by local exciting causes ;
that the local inflammation and degeneration tend to
infect the rest of the system through the blood, and to
set up similar actions elsewhere through reflex nervous
influence. These views have been adopted in the main
by Dr. Bristowe.*

A reference to the recently published views of
Dr. P. W. Lathamf will conclude this part of the
subject. Dr. Latham thinks that some change in the
nervous system is the most important factor in the
etiology of gout ; and that the change is localised in

* " The Theory and Practice of Medicine," fourth edition, p. 874.
f " On the Formation of Uric Acid in Animals," &c., 1884, p. 30.

54 THEORIES AS TO NATURE OF GOUT.

the medulla oblongata or spinal cord, or both, and that
it may be either hereditary or acquired. He considers
(i) that derangement of the hepatic functions leading
to excessive formation of uric acid may be connected
with some "weak spot" in a portion of the medulla
oblongata involving some of the roots of the vagus ;
(2) that uric acid in the blood resulting from hepatic
derangement might act upon any weak spot near the
roots of the vagus and cause gastric troubles, asthma,
cardiac irregularities, &c. ; (3) that if in addition to
some change in the medulla oblongata, those portions
of the spinal cord which control the nutrition of the
joints are affected, articular inflammation with de-
position of sodium urate will become developed.

Such then are the theories now in vogue with regard
to the pathology of gout. The fact that the blood in
this disorder contains urate of sodium is common to
them all, but it is evident that very different views
are held as to the part played by this substance in
the causation of the phenomena. I have given a
somewhat lengthy account of the nervous theory of
the disease, because it is advocated by many dis-
tinguished authorities at the present day, and bids
fair to gain increased acceptance. It appears, how-
ever, to be open to several objections, and cannot, I

THEORIES AS TO NATURE OF GOUT 55

think, be adopted in its entirety, especially in the
form given to it by Dr. Latham.

It must be admitted that disorder of the nervous
system is a prominent feature in many cases of gout ;
but it is surely going too far to assume that this dis-
order is the primary cause of the phenomena, thtfons
et origo mali. Disturbances of the nervous system
are common enough in many disorders universally
believed to be due to the presence of some morbific
matter in the blood, and it is generally thought that
the poison exerts some peculiar action upon the
nervous centres. Now, in gout we have a poisonous
material circulating with the blood, and that the
nervous system should be affected by it is at the
least highly probable, judging from our experience
of fevers, pyaemia, &c. Dr. Latham's ingenious hypo-
thesis of a " weak spot " in the medulla oblongata is
surely unnecessary for the explanation of lithsemia,
and we know too little about a " trophic centre for the
joints" to be able to trace gouty attacks to primary
disorder of that portion of the nervous system. In
the condition known as pyaemia we often meet with
suppurative inflammation of joints far removed from
the original wound. It is highly probable that the
nervous system is deeply concerned in these diffused

56 CONCLUSIONS AS TO NATURE OF GOUT.

" metastatic " inflammations ; but it is clearly im -
possible to assume that antecedent mischief or " weak
spots " in trophic centres determine the incidents and
course of the morbid phenomena.

My theory with regard to gout recognises the cause
of the disorder in the presence of abnormal quantities
of sodium urate in the blood. I am willing to admit
that many of the symptoms are indicative of nerve
disturbances ; but these latter are due to the poisonous
action on the nervous centres, of the materials formed
in the body, and resulting from imperfect metabolism.
The various neuroses which often affect gouty subjects
probably depend upon the operation of the same
cause. The hypothesis of antecedent nervous lesions
is at least unwarranted.

A consideration of the statements contained in the
foregoing paragraphs will, I think, justify the follow-
ing propositions : —

1. Uric acid, in the form of sodium urate, is the

materies morbi of gout.

2. The deposit of sodium urate in the joints is

the cause of the gouty inflammation.

3. This substance is produced in excess, as a result

of the imperfect transformation of albumi-
nous substances.

CONCLUSIONS AS TO NATURE OF GOUT. 57

4. This imperfect transformation is for the most

part due to functional disorder of the liver,
or to excessive supply of nutritive materials,
or, as often happens, to a combination of
these causes.

5. So long as the excess of uric acid is eliminated

by the kidneys, decided attacks of gout may
be absent ; but the symptoms above described
as pertaining to the uric acid diathesis are
liable to be present.

6. The kidneys are apt to become secondarily

affected, owing to the irritation set up by
excess of uric acid and other products of
defective metamorphosis, and by deposits of
urates. Primary disorder of the kidney is
not a necessary factor in the production of
gout.

7. In the majority of cases of chronic gout in-

creased production of uric acid is associated
with defective elimination by the kidneys.

8. The symptoms of nervous disorder in gout are

due to the action of the materia peccans on
the nerve-centres.

5S

CHAPTER IV.

CAUSES OF GOUT.

Predisposing Causes — Heredity — The Acquired Form —
Geographical Distribution — Sex and Age— Climate and
Season — Errors in Diet — Excess of Albuminous Food —
Want of Exercise — Dr. Carpenter on Diet as a Cause
of Gout — Other Alimentary Substances — Starch, Sugar,
and Fats — Acidity — Influence of Fermented Liquors-
Lead — Mental Influence — Depressing Agencies — Excit-
ing causes of Gouty Paroxysms.

Having discussed various theories as to the nature
and immediate cause of gout, and stated my own
views on these subjects, I proceed to consider what
are usually termed the predisposing causes of the
malady. While regarding gout as in very many cases
the result of functional disorder of the liver, it cannot
be denied that other factors of a more or less potent
character often aid in the production of the disease.
I shall therefore devote a few pages to a considera-
tion of the most important of these causes, and also
endeavour to trace the origin of the hepatic derange-
ments.

The hereditary transmissibility of gout has been

HEREDITY AS A CAUSE OF GOUT. 59

proved beyond all question, and in this respect the
complaint manifestly resembles other forms of per-
verted nutrition. Hereditary predisposition can be
traced in about 55 per cent, of all cases, though
probably even this estimate is somewhat too low.
While due weight must therefore be allowed to
hereditary influence, it is, on the other hand, perfectly
certain that gout can be readily acquired. This latter
form generally appears later in life than the hereditary
disease, symptoms of which are often developed at a
very early period. In families in which a gouty taint
exists, the disease is apt to show itself most frequently
and most severely in the younger children, inasmuch
as the dyscrasia generally becomes intensified in the
parents with advancing years. In some instances
the gouty tendency skips over a generation ; the son
of a gouty father perhaps suffers only from indiges-
tion, or exhibits marked obesity, but no definite gouty
symptoms, whereas his offspring are severely affected
by the disease. As a matter of course, the influence
of hereditary predisposition may be greatly promoted
by the patient's habits of life. With regard to geo-
graphical distribution, gout is said to be most common
in England and in the southern provinces of Italy.
Professor Cantani, of Naples, states that in his country

60 SEX AND CLIMATE IN RELATION TO GOUT.

the hereditary tendency has been handed down from
the period of the Greek colonization and the Roman
Empire.

It is not surprising to find that women are much
less liable to suffer from this disease than men ; the
proportion of females to males is somewhat less than
3 per cent. Chronic rheumatism, on the other hand,
is more frequent among women, and thus differs
from gout. It is also worthy of note that in women
the attacks of gout usually come on at a later period
than in men, unless the hereditary tendency is very
strongly marked. Gout very r^-ly develops itself
before the age of eighteen ; first attacks are most
common between the ages of thirty and forty. It is
doubtful whether any particular temperament or
constitution can be regarded as a predisposing cause
of gout.

With regard to climate it cannot be said that this
has any direct effect on the causation of gout. The
complaint is almost entirely confined to the temperate
regions of the earth, and natives of hot countries
(those of Southern Italy excepted) appear to be quite
exempt from any of its manifestations. On the other
hand, Europeans living in hot climates and indulging
freely in animal food and fermented liquors are

ERRORS IN DIET AS A CAUSE OF GOUT. 61

almost as prone to suffer as they would be at home.
In the palmy days of the East India Company, when
high living and copious potations were almost universal,
gout was by no means an uncommon disease among
the servants of the Company, but the climate had no
real share in its production. On the other hand, Dr.
Norman Chevers* thinks that "with all its sanitary
faults Calcutta is an earthly paradise for those cau-
tiously-living people, whom gout threatens, but has
not crippled." It is worthy of note, as showing the
influence of season, that first attacks of gout are
most common in spring and autumn, and that re-
currences are frequent at these periods.

There can be no doubt that errors in diet are the
most potent cause both of functional derangement of
the liver and also of gout, and that when, as too often
happens, deficient exercise is superadded, the develop-
ment of the gouty diathesis is in many cases only a
question of time. Many people habitually take much
more food, especially of the albuminous kind, than the
system requires ; a portion at least of this excess,
after conversion into peptone, is absorbed into the
blood, and conveyed to the liver. Moreover, the

* Medical Times, August 30, 1884, p. 283.

62 ERRORS IN DIET AS A CAUSE OF GOUT.

presence in the stomach of an excessive quantity of
peptone interferes with the dissolving action of the
gastric juice, and imperfectly digested substances are
liable to be absorbed. Congestion and enlargement
of the liver, a state of general plethora, excessive
formation of uric and other acids, and derangement
of the eliminative functions of the kidneys are the
ordinary consequences. Even after the moderate use
of meat, there is increased excretion of uric acid, as
compared with the results of fasting, and when albu-
minates are taken in excess, the increase is very
considerable. Many persons who eat immoderately
also take an insufficient amount of exercise, and
when these two conditions are associated it is difficult
to define the share which each plays in the production
of disease. The disproportion, however, between the
absorbed albuminates and the absorbed oxygen must
result in imperfect oxidation, and its consequences ;
the most important of which are retention in the
system of refuse materials, and irritation of the
eliminating organs (e.g., the kidneys and skin) by the
passage through them of excreta insufficiently pre-
pared for removal from the system. The digestibility
of the food is also a very important point in reference
to the causation of gout. Rich, highly-seasoned dishes,

DIET AS INFLUENCING TYPES OF DISEASE. 63

by causing indigestion, aggravate the effects of an
excessive quantity of food. It must be admitted that
large meat-eaters do not invariably suffer from gout,
and that they sometimes exhibit no signs of obesity.
If a large amount of exercise be regularly taken, the
excess of albuminates appears to be consumed with-
out causing any functional derangements ; and in
some cases, where much food is taken, a large propor-
tion is insufficiently masticated and is not absorbed,
but discharged with the faeces. Albuminuria is a not
unfrequent result of indulgence in excess of albumi-
nous food ; some portion of the excess, it may be
presumed, being thus got rid of.

In connection with this subject the following
observations of Dr. Carpenter* appear to be very
apposite : — " It is worthy of remark that in the times
when even the wealthy lived during four or five
months of the year almost exclusively upon meat,
bread, and flour puddings, and when therefore the
diet was far too highly azotized, as well as defi-
cient in fresh vegetables, Arthritic, Calculous, and
Scorbutic disorders were much more common than
at present. The introduction and universal employ-

* " Principles of Human Physiology," ninth edition, p. 100.

64 EFFECTS OF SUGAR IN CAUSING GOUT.

ment of the potato has unquestionably done much
to correct these two tendencies : on the one hand, by
diluting the azotized constituents of the food, so that
with the same bulk a much smaller proportion of
these is now introduced ; and on the other by supply-
ing to the blood some element which is essential to
the maintenance of its healthy condition. But with
the diminution of the Arthritic diathesis, which the
experience of our older practitioners and the medical
writings of the last century indicate as having taken
place during that period, there has been an increase
in the Rheumatic ; a change which seems to have a
close relation to this alteration in diet."

Opinions differ considerably as to the influence of
the other alimentary substances in the causation of
gout. Dr. Garrod's* views upon several of these points
are somewhat at variance with those usually held, for
he appears to think that sugar, for example, inasmuch
as it has no influence upon the production of uric
acid, may be allowed in cases of gout. It is, on the
other hand, generally believed that sugar, unless in
the most moderate quantities, is almost poisonous to

* Lumleian Lectures, Medical Times and Gazette, 1883, vol. i, p. 553.
Free use has been made of these lectures in the preparation of several of
the following paragraphs.

SUGAR AND STARCH IN RELATION TO GOUT. 65

a gouty subject. This point has an important bearing
upon the question of diet, and it is therefore necessary
to discuss it somewhat minutely. There are three
kinds of sugar met with in food — cane-sugar, grape-
sugar or glucose, and milk-sugar or lactose. Cane-
sugar when taken into the stomach is converted
into glucose, and this substance is very liable to
undergo the alcoholic fermentation. Milk-sugar, on
the other hand, is much less liable to this change,
but in the presence of almost any nitrogenous body it
is very prone to undergo conversion into lactic and
butyric acids. The fermentation of milk-sugar is
especially apt to occur in the presence of cheese. It
is a well-known fact that when starchy articles of
food are taken, the starch is converted into glucose
by the action of the salivary, pancreatic, and intestinal
secretions, and it is therefore obvious that amylaceous
materials may supply the system with large quantities
of sugar. Dr. Garrod doubts whether sugar causes
what is popularly termed acidity, and in advising or
prohibiting the use of sugar, it is important to
discover whether there is any real foundation for the
popular belief on this point. By some persons lumps
of sugar are taken to prevent heartburn, and, as Dr.
Garrod points out, it is scarcely credible that a little

v

66 SUGAR AND STARCH IN RELATION TO GOUT.

cane-sugar would seriously add to the glucose which
is daily produced in the alimentary canal of an in-
dividual living on an ordinary mixed diet It is
tolerably certain that the use of a large quantity of
sugar does not increase the amount of uric acid in the
urine ; but, on the other hand, the influence of sac-
charine and starchy materials upon the production
of fat is well known. These materials are easily
oxidised, and by virtue of this property they delay or
prevent the normal disintegration of the albuminous
constituents of the body. It has also been supposed
that the taking of sugar causes the uric acid to assume
a less soluble form, but it has not been proved that
the acidity of the urine is increased after the use of
sugar in any form. It would therefore seem that the
evil effects of saccharine substances in gouty subjects
are due in great measure to the fact that they retard
metamorphosis. If sugar or starch be taken in excess,
the urine often becomes saccharine.

The remark just made with regard to the influence
of saccharine and amylaceous food in retarding meta-
morphosis, applies also to the fatty and oleaginous
group. The free use of these substances promotes
obesity and prevents waste of tissue, but does not
appear to influence in any degree the elimination of

ACIDITY AND ITS CAUSES. 67

any constituent of the urine. Fatty substances are,
however, very prone to undergo butyric fermentation.
The "acidity" so often complained of by gouty
subjects is the result partly of the fermentation of
food and partly of the increased secretion of gastric
juice. The most obvious symptoms of this condition
are a sour taste in the mouth, acid eructations, acid
reaction of the saliva, and sour odour of the breath.
There is no doubt that in many cases the nature of
the food greatly influences the degree and character
of the acidity. A diet consisting chiefly of vegetables
is, as a general rule, much more productive of this
symptom than one in which animal food largely pre-
ponderates. A reason for this difference could be
easily found if it be assumed that by a process of fer-
mentation, glucose becomes converted into lactic acid,
the presence of which is the cause of the acidity.
Glucose, however, is generally much more prone to
undergo the alcoholic than the lactic fermentation,
although it is theoretically easy to show that one part
of glucose is equivalent to two parts of lactic acid.
This latter, again, is readily converted into butyric acid,
which, in cases of heartburn, is often abundantly present
in the stomach. It is, however, very probable that
sugars and starches often undergo lactic fermentation

F 2

68 ALCOHOL AS A CAUSE OF GOUT.

in the stomach, the gastric mucus, especially when
produced in abnormal quantity, acting as a ferment.
The albuminous substances are capable of under-
going butyric fermentation, either with or without
previous lactic fermentation, and other acids, such as
the acetic, succinic, &c, are often developed at the
same time.

The next point for consideration, namely, the
influence of alcoholic liquors in the production of
gout, is one of great importance. These beverages
are usually classified under the heads of spirits, wines,
and malt liquors. It would seem that alcohol, taken
in the form of brandy, whisky, gin, &c, cannot be
regarded as a cause of gout, inasmuch as in spirit-
drinking countries the disease is almost unknown.
The immoderate use, however, of distilled spirits is a
common cause of disease of the liver and kidneys ;
and where the gouty predisposition exists, any habit
which tends to damage the kidneys must augment
the constitutional disorder. The effect of wine is
more easily demonstrated, but it varies very much in
degree. Full-bodied wines containing much unfer-
mented matter are potent for evil in persons of a
gouty habit, and will doubtless produce the disease
in a large proportion of cases in which there is no

ALCOHOL AS A CAUSE OF GOUT. 69

gouty taint. The light, well-fermented wines, on the
other hand, are not liable to produce gout. The
evidence that the disease is often traceable to the use
of malt liquor is extremely strong. The occurrence
of gout among the poorer classes is, in the absence
of hereditary predisposition, almost always due to
excessive consumption of beer.

The case with regard to alcohol as a cause of gout
may therefore be summed up by saying that distilled
spirits and the lighter wines appear to be innocuous in
this direction, while malt liquors of all kinds, and the
stronger and imperfectly fermented wines (comprising
port, sherry, madeira, and champagne), play a very
conspicuous part in the causation of gout. We have
no definite knowledge as to the mischievous principle ;
it may be, as Dr. Garrod believes, a something which
is the result of imperfect fermentation, for it is certain
that those beverages in which fermentation has been
prematurely checked are much more liable to produce
gout and gravel than those in which the process has
been allowed to attain completion. The natural
acidity of wines plays a very small part in the pro-
duction of the gouty diathesis ; but that acid wines
often excite a paroxysm in gouty subjects is a matter
of common observation.

70 LEAD-POISONING AND GOUT.

The influence of lead as a predisposing cause of
gout is a subject of considerable interest, for there can
be no doubt as to the frequency of the coincidence of
lead-poisoning and gouty manifestations. In many
of the recorded cases it is probable that other factors
assisted in the production of the disease ; but cases
of gout for which no other causes can be discovered
are occasionally noticed. It is somewhat curious that
in France, where lead-colic is common, gout is a very
rare disease, and this fact lends weight to the sup-
position that the effect of the lead is often much
heightened by indulgence in alcoholic liquors. In
lead-poisoning the blood is rich in uric acid, while the
urine is deficient in this substance. It is doubtful
whether there is increased production of uric acid, or
defective elimination, but the latter condition would
appear to prevail. There is another curious relation
between lead-poisoning and gout, for it is highly
probable that persons of a gouty habit are more
liable than others to suffer from the effects of the
mineral. Even in medicinal doses salts of lead are
wont to cause very marked symptoms in gouty sub-
jects.

There is one other predisposing cause of gout
which deserves a passing notice, and especially

EXCITING CAUSES OF GOUT. 71

because it is connected with one of the current
theories of the nature of the disease. Sydenham
found that, in his own case, an attack of gout could
be excited by severe study, and in some gouty
persons anxiety of mind, grief or annoyance produce
the same effect. It is, however, scarcely credible
that mental influences alone should suffice for the
development of the gouty diathesis. Severe study is
often associated with sedentary habits and errors in
diet, which, as I have just attempted to show, are
potent causes of gout. With regard also to other
depressing influences, such as exposure to cold,
sexual excesses, and the like, these no doubt often
excite a paroxysm, and may even aid in the develop-
ment of the diathesis ; but in this latter respect they
are not to be compared with the causes already
discussed.

A few words as to the exciting causes of the
paroxysms will conclude this portion of the subject.
Experience teaches us that wherever the predisposi-
tion exists, almost anything, whether of an exciting
or debilitating character, that disturbs the health, is
capable of inducing an attack. The most common
exciting causes are therefore excesses in eating and
drinking, indigestible food, articles of diet which

72 EXCITING CAUSES OF GOUT.

disagree with the patient's idiosyncrasy, exposure to
cold, excessive mental exertion, violent bodily exercise,
mental excitement, venereal excesses, debilitating
diseases, loss of blood, &c. The action of one at
least of these causes is very generally recognised. In
some gouty subjects pains in the joints, or even an
acute attack, are the ordinary results of taking even
two or three glasses of port or champagne. In addi-
tion, however, to causes of a more or less general
nature, it not unfrequently happens that local injuries,
whether of a severe or slight character, are sufficient
to induce an attack. Thus operations and fractures
of various kinds, bruises, sprains, and even the wearing
of a tight boot, may act as exciting causes. In gouty
subjects very slight local injuries often give rise to
unusually persistent and severe pain which is not
relieved by ordinary remedies, but subsides under
appropriate treatment. Acute gout, moreover, some-
times attacks a joint which has suffered in some
previous injury.

73

CHAPTER V.

IRREGULAR MANIFESTATIONS OF GOUT— VISCERAL
AND CUTANEOUS AFFECTIONS.

Irregular Gout — Suppressed Gout — Peculiarities of the
Irregular Manifestations — Detection of Uric Acid in
the Blood in these cases — Visceral Gout — Functional
and Organic Affections — Gouty Diseases of the Throat
and Stomach — Dr. M. Mackenzie's Cases of Gouty Throat
— Retrocedent Gout of the Stomach — Two Forms :
Spasmodic and Inflammatory — Dr. Buzzard on Proba-
bility OF MISTAKING GASTRIC CRISES OF TABES FOR GOUT

of the Stomach — Question of Metastasis— Experimental
Production of the Phenomena of the Uric Acid Dia-
thesis— Gouty Affections of the Heart — Retrocedent
Gout — Condition of Heart in Fatal Cases — Fatty
Degeneration — Gouty Phlebitis — Gouty Affections of
the Lungs : Asthma and Bronchitis— Dr. Stores' Views
— Dr. Greenhow's Cases — Gouty Affections of the
Nervous System — Gout retrocedent to the Brain-
Neuralgia, Headache, &c, in Gouty Subjects — Gouty
Neuritis— Disturbances of the Sensorial Functions —
Gout and Eczema — Dr. Piffard's Views on the Con-
nection between certain Skin Diseases and the Rheu-
mic Diathesis.

There is no difficulty in recognising the paroxysms
of regular gout. The suddenness of the attack, the
seat and character of the pain, and the condition of

74 IRREGULAR MANIFESTATIONS OF GOUT.

the joint are sufficient to determine the diagnosis.
There are, however, many other phenomena connected
with the disease, but of a far less definite character,
though due to the same cause, viz., the presence in the
blood of excess of sodium urate. I propose to discuss,
without unnecessary detail, the most important of
these manifestations, to which the term irregular may
be conveniently applied.

In former times a vast number of symptoms were
referred to gout. At the present day a very different
tendency prevails, and we hear more about " neurotic
conditions," " trophic nerves and lesions," and the like.
Some modern authorities indeed assert that the term
" gout " is very often a refuge for ignorance ; implying
that when no other cause can be discovered the phrase
" suppressed gout " is clutched at in desperation, in
order to evade a serious difficulty. There is probably
some amount of truth in this insinuation, but at the
same time it is not unreasonable to assume that the
same cause or causes which give rise to regular — i.e.,
articular — gout are capable of producing certain effects
or symptoms in parts of the body other than the
articular structures. It must, I think, be admitted
that a high degree of probability is attached to this
supposition, and that it is perfectly justifiable to speak

IRREGULAR MANIFESTATIONS OF GOUT. 75

of irregular manifestations of gout. It is a matter of
common experience that certain symptoms, such as
those already mentioned as connected with the uric
acid diathesis, often precede the acute attack, disappear
on its occurrence, and again become troublesome when
the articular symptoms have subsided. We also find
that many patients exhibit symptoms of the diathesis,
but never suffer from decidedly acute attacks, and there
is no escape from the conclusion that both classes of
manifestations are due to the same cause. It is not
of course contended that all symptoms which may
occur, even in decidedly gouty subjects, are necessarily
due to the diathesis ; but it is extremely probable
that a gouty taint modifies the course and symptoms
of any disorder which affects its subject.

In cases at all urgent, before arriving at a conclu-
sion with regard to symptoms suspected to be due
to gout, it is well to adopt Dr. Garrod's suggestion
and examine the blood-serum obtained from a small
blister in the manner already described. If crystals
of uric acid are discovered it is highly probable that
the suspicion is correct. As a matter of course, the
age, sex, previous history, habits of life, and other
circumstances must be duly considered. The previous
occurrence of an acute attack of gout is clearly

76 VISCERAL GOUT.

suggestive of the causation of anomalous symptoms,
subject to the caution given in the preceding paragraph.

In my first chapter I cited Cullen's classification of
the various forms of gout. The terms atonic and
wandering are at the present day almost obsolete ; we
now speak of visceral gout, which includes misplaced,
rctrocedent, and atonic forms. This collective term is
applied to designate all symptoms having their seat
in internal organs, and presumably due to the influence
of the gouty diathesis. The visceral affections are
again further subdivided into functional and organic.
An important addition must, however, be made to
this category, for, as I shall presently endeavour to
show, certain skin-affections are closely connected with
the gouty diathesis, and may, indeed, be reckoned
among its most important manifestations. In the
present chapter I propose to deal with these affec-
tions and with gouty disorders of some of the thoracic
and abdominal viscera, leaving, however, goutydiseases
of the liver and kidneys for a subsequent chapter.

Symptoms of visceral gout may precede the articular
inflammation, may co-exist with it, or may suddenly
appear on its subsidence. Many of the symptoms of
the uric acid diathesis (see page 45) may be regarded
as those of visceral gout in an incipient stage. Gouty

GOUTY ANGINA AND DYSPEPSIA. 77

disorders of the digestive organs are common pre-
cursors of an attack of gout, and in my experience
often occur alone, that is, without any decided
articular affection. The throat is not unfrequently
affected in gouty patients, the symptoms of angina
sometimes alternating with attacks of inflammation
of the joints. Dr. Morell Mackenzie* has recorded
several well-marked instances. " In one case, a gentle-
man who frequently suffered from attacks of angina
became subject to gout, and was never again attacked
with inflammation of the throat. In another case,
the patient was suffering from acute pharyngitis,
when the symptoms suddenly disappeared, and an
acute attack of gout developed in the great toe of the
right foot ; after three days the gouty inflammation
of the toe disappeared and acute hyperemia of the
pharynx supervened."

Dyspepsia in various forms — acidity, flatulence,
irregular action of the bowels and haemorrhoids, are
common symptoms in gouty subjects and in persons
in whom the hereditary tendency is well marked.
Their connection with gout is rendered probable,
first by their subsidence on the occurrence of an acute

* " Diseases of the Throat and Nose," vol. i, p. 48.

78 RETROCEDENT GOUT.

attack, and, secondly, by the manner in which they
are influenced by regimen and medicines suitable to the
gouty diathesis. Charcot records a case which illus-
trates the first of these characteristics. A patient,
who had suffered from articular gout, became a martyr
to dyspepsia, and, after vainly invoking the aid of
regular science, had recourse to homoeopathy. The
dyspepsia rapidly subsided and the patient was con-
gratulating himself on his change of advisers when
a sharp attack of articular gout served to explain the
supposed cure.

More important, in some respects, than this mis-
placed gout of the stomach are those attacks to which
the term retrocedent is commonly applied. It is im-
possible to suggest any really satisfactory explanation
of the so-called " metastasis," but cases undoubtedly
occur in which violent gastralgia, vomiting, prostra-
tion, or even death, abruptly supervene upon the
subsidence of the symptoms of articular gout. In
some cases the metastasis is spontaneous ; in others,
it appears to result from attempts to relieve the
articular inflammation by local remedies, or from
exposure to cold or other injurious influences, during
the course of an acute attack. In a case which came
under my notice, a gentleman, aged forty-four, suffer-

GOUT OF THE STOMACH. 79

ing from acute gout, applied cold wet cloths to the joint.
Symptoms of acute gastritis rapidly supervened, and
were followed by syncope and death in seventeen hours.

Cold applications to the affected joint or placing the
foot in cold water will often relieve the local symptoms,
but at the cost of serious gastric or cardiac disorder,
and a full dose of colchicum has also been known to
produce similar results.

Gout thus affecting the stomach presents at least
two forms, which may be termed respectively spas-
modic and inflammatory. In the former, which may
be regarded as a functional affection, there is violent
spasm or cramp in the epigastric region, accompanied
by a feeling of intense oppression and distension,
nausea, vomiting, difficulty of breathing, and palpita-
tion of the heart. There is also great prostration ;
the skin is cold and clammy, and the pulse is feeble,
frequent, and irregular. There is, however, no severe
burning pain, and the cramp is relieved by pressure
and stimulants. In the inflammatory form, the
symptoms are those of acute gastritis. There is
severe epigastric pain of a burning character and
much aggravated by pressure, nausea and vomiting,
and more or less febrile disturbance, and the ejected
matters sometimes contain blood. The pulse is at first

80 GOUT OF THE STOMACH.

full and strong, but soon becomes feeble and irregular.
Stupor is apt to supervene, and the patient becomes
almost insensible ; but slight pressure upon the epi-
gastrium calls forth evidences of severe pain. These
symptoms, like those of the spasmodic form, may
either suddenly subside, or terminate in death. Recur-
rence of the articular inflammation is sometimes simul-
taneous with the abatement of the gastric symptoms.
Certain phenomena much resembling those of
acute gouty disorder of the stomach are not unfre-
quent in cases of locomotor ataxy. Dr. Buzzard,*
indeed, in his excellent Lectures, suggests " that many
cases of so-called ' gout in the stomach ' would be
found, if examined by the light of our present know-
ledge, to be examples of tabes dorsalis, with gastric
crises. The lightning pains, which would probably
be associated with the sickness and epigastric pain,
would be likely in the minds of many to make the
diagnosis of 'gout in the stomach' complete." Severe
gastric attacks, it must be remembered, are sometimes
witnessed in persons who, although examples of tabes
dorsalis, "show at the time no sign of inco-ordination
of movement." Their persistence and frequent recur-

* " Clinical Lectures on Diseases of the Nervous System," p. 272.

METASTASIS OF GOUT.

rence would suffice to exclude gout as a cause, and if
accompanied by absence of patellar tendon-reflex and
by other indications of tabes, there ought to be no
difficulty in the diagnosis.

When gout retrocedes to the intestines, the sym-
ptoms take the form of diarrhoea or colic. These
organs, however, are far less subject to gouty in-
fluences than the stomach, and very few trustworthy
reports of gouty enteritis or colic, due to metastasis,
are to be found in medical literature.

This subject of metastasis, or transfer of diseased
action, is involved in much obscurity, and not a few
authorities assert that symptoms such as those above
described are capable of a very different explanation.
The old notion of metastasis was to this effect — a
local irritation, due to some permanent general dia-
thesis, becomes cured or subsides, but throws itself on
some other part in which it excites symptoms of dis-
ordered action or of inflammation. That this is the
apparent course of events there can be no doubt, but
as to the manner in which the irritation is propagated
we can only speculate. It is very probable that in
many instances of supposed metastasis, the occurrence,
e.g., of gout in the stomach, was a mere coincidence,
and that the symptoms were only those of severe

G

82 METASTASIS OF GOUT

indigestion, to which gouty subjects are especially
liable. Chronic gastritis is a common condition in
these patients, and the symptoms of gastric disorder
are easily aggravated, and become prominent under
the operation of comparatively slight causes. Ad-
mitting, however, that in some cases the phenomena
of retrocedent gout, or gout of an internal organ, are
due to a previously existing affection, it is going too
far to assert that all instances of retrocedence can be
thus explained. Charcot points out that phenomena
analogous to those of the uric acid diathesis can be
experimentally produced in animals, and that in such
cases the gastric juice and the follicles of the stomach
are loaded with sodium urate. He thinks that, with-
out assuming the existence of an identical condition
to account for the symptoms of stomachic gout,
superficial lesions might be easily caused in the
digestive system under the influence of retrocession.
However this may be, "it is probable that in the long
run, permanent lesions are produced in the cases in
which these manifestations occur, which seem so
purely functional."*

Of the organs of the thorax, the heart often becomes

* Charcot, " Lectures on Senile Diseases," New Syd. Soc. Trans., p. 85.

GOUT AFFECTING THE HEART. 83

affected in cases of gout, and the disorder may be
either functional or organic. Functional disorder is
evidenced by palpitation, precordial oppression, more
or less dyspnoea, and irregularity of pulse. These
symptoms are in many cases merely those of dyspep-
sia, or of an overloaded stomach, and are in no way
characteristic of gout. They, however, frequently
accompany the development of the uric acid diathesis,
and, in some cases at least, are probably due, not
directly to indigestion, but to the action upon the
heart of the sodium urate contained in the blood.
These cardiac symptoms not unfrequently subside
when the acute attack supervenes and subsequently
reappear, thus alternating with the joint-affection.

In considering retrocedent gout affecting the heart,
the difficult question of metastasis again comes before
us. Cases, however, now and then occur in which the
morbid action appears to be transferred from the joint
to the heart. I have already referred to one case in
which gastric symptoms were followed by fatal syn-
cope. In one recorded case a patient suffering from
severe articular gout applied snow to the affected part.
The pain was relieved, but marked symptoms of
syncope came on, and the patient was for some time
in a very critical state. In another case, under the

G 2

84 GOUT AFFECTING THE HEART.

care of Dr. Garrod,* the cardiac symptoms followed
exposure to cold east winds at a time when the
patient was recovering from an acute attack. There
was violent pain across the chest and down both arms,
with faintness and a sense of alarm. The symptoms,
after partial subsidence, recurred several times, and a
few days after their final disappearance the foot again
became affected. " There was no evidence of struc-
tural disease of the heart, and no appreciable febrile
disturbance."

Whatever may be the true explanation of these and
similar cases, the condition of the heart, when death
occurs from retrocedence of gout to that organ, is
always sufficient to account for the symptoms and the
result. Fatty degeneration or fatty deposit, with or
without valvular disease, and dilatation, are invariably
present. An increased amount of fat on the surface
of the heart, accompanied by atrophy of the muscu-
lar tissue, is common in gouty persons presenting
external signs of obesity. In all these conditions,
shortness of breath, or a sense of choking or suffoca-
tion, a tendency to faintness. especially on exertion ;
a feeble cardiac impulse, and a small, slow, and ir-

* " Gout and Rheumatic Gout," third edition, p. 440.

GOUT AFFECTING THE HEART. 85

regular pulse are usually more or less prominent
symptoms, but it is well known that these are some-
times absent in cases in which extensive degeneration
is discovered after death. In other cases there are
symptoms of angina pectoris, which in gouty subjects
is almost always accompanied by organic changes.

In these cases of fatty degeneration of the heart,
rupture of the organ is the most frequent cause of a
suddenly fatal termination. Death may also occur
from syncope, without rupture. If it be admitted that
retrocedent gout may give rise to symptoms of cardiac
disturbance in the absence of structural disease of the
organ, it is only reasonable to expect that the same
cause would produce much more serious consequences
when organic lesions are present. It is not necessary
to assume that gout sets up any kind of inflammation
of the heart, but those factors which are most potent
in the development of gout tend also to produce fatty
changes in the organ. Gout, moreover, as I shall
presently attempt to show, plays an important part in
the causation of Bright's disease, and is thus again
connected with cardiac disorders. Gout also appears
to be one predisposing cause of atheroma, which,
when it affects the coronary arteries, often gives rise
to fatty degeneration.

86 GOUTY PHLEBITIS.

In connection with the circulatory organs, gouty
phlebitis requires to be briefly noticed. Inflammation
of the veins, especially in the lower limbs, is some-
what liable to occur in gouty subjects, and either with
or without acute attacks in the joints. The superficial
veins are those which are most frequently affected ;
the inflammation begins very suddenly, and causes
severe pain and tenderness. It may spread con-
tinuously, and may appear simultaneously in several
veins. It sometimes disappears and affects other
veins at a distance. Sometimes the deep veins are
affected, in which case the limb becomes cedematous
and distended. The inflammation is apt to recur, and
hence recovery is often tedious. Symptoms of em-
bolism have been known to supervene, with death
from obstruction of the pulmonary artery as a result-
Sir James Paget* says that gouty phlebitis is often
hereditary, and that common phlebitis is often trace-
able to the gouty diathesis. He thinks that gout
should always be suspected whenever phlebitis occurs
without evident external cause in an elderly person.
Dr. Owen Rees thinks that gout is essentially a
capillary phlebitis, and that this theory best explains

* " Clinical Lectures and Essays," p. 300, See also Sir P. Hewett's
Address in Clin. Soc. Trans., 1873.

GOUTY ASTHMA AND BRONCHITIS. 87

the phenomena of the acute paroxysm, the venous
inflammation being caused by the circulation of a
blood-poison.

If we turn to diseases of the respiratory organs, we
find that asthma and bronchitis are often connected
with the gouty diathesis. In some cases of gouty
asthma, there is no organic affection of the respiratory
apparatus, while in others, bronchitis or emphysema
co-exists. The connection between the asthma and
the diathesis is shown by the fact that the former
either subsides or remits on the development of
articular inflammation.

There is still stronger evidence in support of
the connection between gout and bronchitis. When
we consider that many specific disorders are frequently
accompanied by affections of the bronchial mucous
membrane, it is not to be wondered at that a disease
like gout should be liable to the same complication.
I have witnessed the symptoms of acute articular gout
disappear on the supervention of bronchitis. Crystals
of uric acid have been detected in the sputa of a gouty
patient,* and scarcely any stronger evidence could be
offered of the occurrence of gouty bronchitis. There

* See note by the late Dr. Hudson on page 81, New Syd. Soc.
edition of Stokes " On Diseases of the Chest."

S8 GOUTY BR 0NCH1TIS.

is every reason to believe that all the excretory organs
take a share in the elimination of morbid materials, and
that catarrh or inflammation is a frequent result. The
proof that the bronchial symptoms are connected with
gout is found in the fact that they often precede the
attack and rapidly subside on its appearance, again
to recur when the articular inflammation abates. In
the case of a lady aged seventy, recently under my care,
attacks of acute gout had been very frequent for some
years ; bronchitis supervened and the gouty attacks
diminished in number and severity. Dr. Todd* has
recorded a case in which obstinate and severe
bronchitis at once subsided on the appearance of gout
in the foot ; and Dr. Stokes alludes to cases in which
bronchial symptoms having been removed by appro-
priate treatment, an attack of gout immediately
appeared. He also refers to more complicated cases,
such as the succession of epilepsy, gout, and fatal
bronchitis ; inflammation of the trachea, slight general
arthritis, glandular enlargements, and gout. He doubts
whether in such cases, the anatomical characters of
the lesion are different from those of ordinary bron-
chitis, and thinks that "its specific character will be

* " On Gout and Rheumatism," p. 38.

GOUTY AFFECTIONS OF THE NERVOUS SYSTEM. 89

found more in its mode of invasion and amenability
to certain remedies than in its anatomical nature ©r
seat." Valuable clinical evidence with regard to the
relation between a gouty constitution and bronchitis
has been adduced by Dr. Headlam Greenhow.* He
has given details of many interesting cases showing
the frequency of gout among bronchitic patients ; the
frequent co-existence of gout and bronchitis in the
same families ; the alternation of the two affections
in the same persons, and the frequent association of
psoriasis, eczema, and gravel with bronchitis. Pleurisy
and pneumonia are not unfrequent in gouty subjects,
but it is doubtful how far the diathesis is concerned
in their development.

Severe and well-marked gouty affections of the
nervous system are of less frequent occurrence, but
retrocedent gout sometimes attacks the brain and its
membranes. The supervention of cerebral symptoms
upon the sudden disappearance of gout from an
extremity has been observed by Dr. Garrod, and
Niemeyer mentions two cases of gouty subjects pre-
senting severe symptoms referable to circumscribed
inflammation of the meninges. In one case the

* " On Bronchitis and the Morbid Conditions connected with it,"
second edition, p. 128, etseq.

90 GOUTY AFFECTIONS OF THE NERVOUS SYSTEM.

symptoms disappeared simultaneously with a copious
excretion of urates by the kidneys ; and in the other,
with an attack of gouty inflammation of the joints.
Retrocedence of gouty inflammation, giving rise to
apoplexy, has been known to follow the application of
cold to a gouty joint, but as in the analogous case of
the heart, it is probable that in the majority of instances,
more or less severe organic disease had previously
existed in the part. Epilepsy would appear in some
cases to be connected with gout, the convulsions
ceasing after the development of acute arthritic
attacks.

There is much reason for believing that many slight
affections of the nervous system are referable to the
presence of the gouty diathesis ; the term nervous
gout has indeed been applied to the entire class of
irregular gouty manifestations. Nervous affections
of this character occur especially in women, and
in individuals generally of a nervous temperament
and descended from gouty ancestors. In some
families the male members are the victims of acute
gout, while the females suffer from neuralgia in
various forms, headache, &c. As in other cases, the
connection of any obscure symptoms with gout may
be suspected when there is a history of the disease in

GOUTY NEURALGIA.

the family and no other cause can be detected. When
the symptoms alternate or co-exist with slight attacks
of articular inflammation, there can be little doubt as
to their origin. Cases are sometimes met with in
which patients, once the subjects of frequent articular
attacks, become after a time exempt from them, but
suffer instead from neuralgia, headache, sleeplessness,
vertigo, dizziness, and other symptoms of nervous
disorder. Neuralgia is the most common symptom
of nervous gout, and it most frequently appears in the
form of hemicrania or megrim. In the case of a
lady, aged sixty-seven, whom I saw with Sir William
Jenner, gout and diabetes co-existed, and the patient
suffered also from occasional attacks of megrim,
with distressing sickness and intolerance of light.
Dr. Liveing thinks that there can be no question
" as to the frequent connection of megrim, whether
in its blind, sick, or simply hemicranial forms, with
a gouty diathesis, and its occasional replacement
by fits of regular gout. Megrim, however, is far
from being the only neurosis which is thus associated
with gout."* As stated in a previous chapter (see
page 52), Dr. Liveing is inclined to think that gout in

* "On Megrim, Sick Headache, and some Allied Disorders," 1873,
p. 404.

92 GO UTY NE URAL GIA.

its various forms is the manifestation of a disorder
which has its primary seat in the nervous system itself.
Other forms of neuralgia are not uncommon
in gouty subjects ; sciatica and facial neuralgia,
for example, sometimes alternate with articular
gout. We may assume that the pain is due to
hyperemia and oedema of the neurilemma, but
why only certain branches of a nerve should be
affected as a result of the constitutional disorder is a
question which cannot be solved. Dr. Buzzard has
pointed out that the " lightning-like " pains of tabes
are not unfrequently ascribed to gout or rheumatism.
It is probable that gout is for the most part only a
predisposing cause of neuralgia, and that the excite-
ment of the pain is due to the operation of other
causes. Dr. Graves was of opinion that "gouty
inflammation of the nerves and their neurilemma may
in process of time extend to the spinal marrow and its
investments, and give rise to derangements terminating
in ramollissement and structural degeneration." He
has described several cases of gouty paralysis.*

* For evidence in support of the view that inflammatory processes in
nerves may be propagated to the cord, see Leyden's essay on "Reflex
Paralysis," German Clinical Lectures, New Syd. Soc, p. 163. Also
Nothnagel's essay on Neuritis in the second series of Lectures.

GOUTY ECZEMA.

f)3

Various disturbances of the sensorial functions often
occur in gouty subjects and take the form of vertigo,
dizziness, tinnitus aurium, perversions of vision, &c.
I am now attending a gouty subject in whom vertigo
is very marked and troublesome. There is, of course,
nothing peculiarly characteristic in these symptoms
of nervous irritation, for they are common indications
of dyspepsia. Sometimes, however, they alternate
with sub-acute attacks of articular gout, subsiding
when the inflammatory symptoms are prominent, and
recurring shortly after their disappearance. Under
these circumstances their connection with the gouty
diathesis would appear to be unquestionable. Other
manifestations of nervous disorder in gouty subjects,
such as cramps in different parts of the body, hysteria,
hypochondriasis and maniacal attacks, may, in some
cases at least, be placed in the same category.

I have already referred to the fact (see p. 47) that
eczema often alternates with symptoms referable to
gout, and I have found the association to be of such
frequent occurrence that I regard the skin-affection in
these cases as a decided manifestation of the gouty dia-
thesis. This view is advocated by many authorities ;
among others, by my friend Mr. Wyndham Cottle, who
informs me that he considers the eczema, in common

94 GOUTY SKIN-AFFECTIONS.

with the other irregular symptoms, as but a local
manifestation of the same constitutional state. Dr.
PirTard,* Professor of Dermatology in the University
of New York, has entered very fully into this subject,
and his remarks are so consonant with my own obser-
vations that I venture to quote them. In opposition
to the Vienna school, he believes in the existence of
a certain cutaneous diathesis, which he designates as
rhenmic, this being equivalent to the dartrous diathesis
of the French, and the predisposing cause, he assumes,
of eczema, psoriasis, and pityriasis. This diathesis
also corresponds with the condition known in England
as UtJicemia, or, in other words, with the uric acid
diathesis. The state of the blood in lithsemia has
been already fully described, and it is a remarkable
fact that uric acid has been detected in the scales
and excretions of the skin-affections just mentioned,t
and that, as described by Dr. Garrod, the administra-
tion of uric acid internally has been followed by an

* A Treatise on the Materia Medica and Therapeutics of the Skin,"
1 88 1, p. 126, etseq.

f In several cases of patients lying bedridden from rheumatic gout,
in whom one or both legs were covered with an eczematous eruption,
the late Dr. Golding Bird observed microscopic crystals of sodium
urate scattered like fine hoar-frost on the parts on which the surface-
exudation had dried.

GOUTY SKIN-AFFECTIONS.

95

eczematous eruption.* It would therefore seem that
these cutaneous affections are really due to ac-
cumulation in the blood of certain excrementitious
substances, of which uric acid is the one most easily
demonstrable. Dr. Piffard thinks that the category
of noxious agents includes also lactic acid, oxalic acid,
creatin, and creatinin ; all of these representing either
steps or side-products of the processes which bring
about the metamorphosis of food into tissue, and that
again into substances ready for excretion. If we
regard the normal process as one of oxidation,
the production in excess of these excrementitious
materials may be assumed to result from sub-oxi-
dation.

So long as these products are removed by the
kidneys, there may be no evidences of any injurious
action ; but when the excess becomes too great, or
when the eliminative functions of the kidneys are
imperfectly performed, the work is thrown upon
other organs, and especially upon the skin, and
the result in many cases is an outbreak of eczema,
psoriasis, or pityriasis. These affections obviously
present a mutual relationship, and possess many

* Lumleian Lectures, Medical Times and Gazette, vol. i, 1883,
p. 31*.

96 GOUTY SKIN-AFFECTIONS.

features in common, and they often alternate not
only with affections of the joints, but with symptoms
referable to the pulmonary and gastric mucous
membranes. Psoriasis and eczema are often here-
ditarily transmitted, and in some cases they appear
to be the only manifestation of the gouty diathesis
which is thus handed down. According to Dr.
Garrod, prurigo must be added to this list. As
additional evidence of the connection between these
skin-affections and gout, it should be mentioned that
they are almost invariably aggravated by causes
which increase the production of uric acid ; whereas
they are improved by constitutional treatment and
regimen, but either not influenced at all, or else made
worse by ordinary remedies. They are, moreover,
very liable to recur so long as the original diathesis
remains unchanged.

97

CHAPTER VI.

HEPATIC AND RENAL DISORDERS CONNECTED WITH
GOUT.

Hepatic Congestion frequent in Gouty Subjects— Inflam-
mation of the Biliary Ducts, Jaundice, &c. — Gouty
Cirrhosis of the Liver — Question as to its Causation
— Influence of other Substances besides Alcohol —
Dr. Budd's Views — Biliary Concretions in Gouty
Subjects — Renal Disorders due to Imperfect Assimila-
tion and Hepatic Derangement — Albuminuria as a
Symptom — Question as to Physiological Albuminuria —
Dr. Senator's Views — Digestion-Albuminuria — Influence
of Albuminuria upon the Kidneys — Question as to
Indication of Renal Mischief when "Digestion-Albu-
minuria" is observed — The "Gouty Kidney" properly
so-called, varieties of — Association of Infarctions of
Urates with Renal Cirrhosis — Symptoms of Gouty
Kidney — Gravel, Calculus, Bladder-Affections, and
Diabetes in Gouty Subjects.

The part taken by functional disorders of the liver in
the causation of gout has been fully described in pre-
ceding chapters. Following out the view, so forcibly
advocated by the late Dr. Murchison, that lithcemia is
very often due to functional hepatic derangement, I
have sketched, somewhat minutely, the symptoms and

h

HEPATIC CONGESTION IN GOUT.

causes of the uric acid diathesis, of which gout is to be
regarded as a further development. I have stated my
belief that a normal condition of the structure of the
kidneys generally obtains during the early stages of
gout, and that gouty disease of these organs is a con-
sequence of the irritation to which they are subjected
during the elimination of the excess of sodium urate,
and other products of defective metamorphosis. It
must of course be admitted that renal disease of
independent origin sometimes exists previously to
any gouty manifestation, and that defective capacity
of the kidneys will promote the development and
accelerate the course of the disorder. I now propose to
consider those hepatic and renal diseases which, so to
speak, follow in the train of gout, and may be regarded
as more or less direct effects of the dyscrasia.

That the liver is rarely healthy in gout is a point
of common observation ; but it is at least doubtful
whether there are any organic affections of this organ
directly chargeable to the gouty diathesis. I have
already referred to the symptoms of hepatic conges-
tion often present in gouty subjects ; but those are
for the most part of a temporary character, are much
relieved by proper diet and treatment, and frequently
disappear when the articular inflammation comes on.

GOUTY INFLAMMATION OF THE BILIARY DUCTS. 99

On the other hand, a paroxysm of gout is some-
times attended by bilious vomiting and purging and
other signs of hepatic disorder. Dr. Murchison states
that adult persons of a gouty constitution are especially
liable to attacks of inflammation of the biliary ducts,
generally as a result of extension of catarrh of the
stomach and duodenum, and preceded by symptoms
referable to these parts. In some cases the symptoms
of inflammation of the biliary ducts become very
severe ; the frequent vomiting, the emaciation, and
the persistent jaundice have sometimes led to the
suspicion of cancer. Under treatment by purgatives,
colchicum, and alkalies, the symptoms gradually pass
off. This affection is generally noticed in persons
descended from gouty ancestors, but presenting no
decided manifestations beyond occasional twinges of
pain in some of the smaller joints. In other instances
the jaundice and other symptoms referable to the
liver appear on the subsidence of an acute attack
of articular gout. A case of this kind has recently
come before me. A lad)', aged forty-four, of gouty
family history, had had several acute attacks in the
right toe-joint ; during the intervals she had suffered
much from flatulence and other symptoms of dys-
pepsia. When called in to see her, I found her

n 2

ioo GOUTY CIRRHOSIS OF THE LIVER.

suffering from jaundice and considerable pain in the
hepatic region. A week previously an acute attack
in the joint had suddenly abated, in consequence (as
she thought) of a chill, and the hepatic symptoms
appeared two days afterwards.

A gouty form of cirrhosis of the liver has been
supposed to occur, but the evidence on this point
cannot be regarded as quite conclusive. The two
conditions not unfrequently co-exist ; but their union
in such cases is probably due to the operation of the
same causes. Trousseau's description of gouty chronic
hepatitis is exactly applicable to ordinary cirrhosis.
He states that it "is characterised by pains in the
right hypochondrium ; by an increase or diminution
in the volume of the liver, rendered appreciable by
palpation and percussion ; by jaundice, or at least by
a sub-icteric tint of the skin. At the autopsy, the
substance of the organ is often found exceedingly
hard, granular, like cirrhosis, and (according to
Lieutaud) charged with calcareous concretions."* The
excessive use of alcohol, especially in the form of raw
spirits, is universally recognised as the ordinary cause

* "Lectures on Clinical Medicine," New Syd. Soc. Trans., vol. iv.
p. 381.

GOUTY CIRRHOSIS OF THE LIVER. 101

of cirrhosis ; but Dr. Budd* has suggested " that there
may be other substances, among the immense variety
of matters taken into the stomach, or among the
products of faulty digestion, which, on being absorbed
into the portal blood, cause, like alcohol, adhesive
inflammation of the liver." This view is certainly
deserving of consideration. It is well known that
a temporary enlargement of the gland occurs during
digestion, and is relieved by an increased secretion
and flow of bile. When the congestion frequently
exceeds the normal limit (whether the cause be alcohol
or articles of food of an irritant nature) it may easily
become the starting-point for structural disease. It
would seem therefore not improbable that, just as
gout may arise from over-supply of food, with little
\{ any excess of alcohol, so hepatic cirrhosis may
sometimes own a similar origin. The fact that this
disease has been observed in animals (the cow and
pig) is sufficient to prove that it is not always due to
the use of alcohol.

Biliary concretions are not often noticed in gouty

* "Diseases of the Liver," third edition, 1857, p. 151. Professor
Tbierfelder doubts whether cirrhosis of the liver ever results from gouty
dyscrasia on the ground that the complaint is not common in gouty
subjects, and is not attended by deposits of uric acid in the diseased
organ. Ziemssen's Cyclopaedia, vol. ix, p. 172.

102 BILIARY CONCRETIONS AND GOUT.

subjects. Dr. Prout, however, thought that a tendency
to the formation of gall-stones of cholesterin is fre-
quently associated with a tendency to lithic-acid
deposits in the urine. This view was supported by
Dr. Budd (p. 369). " It is probable that in London
the habit of drinking porter, which frequently leads
to lithic-acid deposits and to the most inveterate
forms of gout in persons who inherit no disposition to
them, may also frequently lead to the formation of
gall-stones." The fact appears to be that gout and
biliary calculi often own a similar causation, e.g.y
errors in diet, sedentary habits, &c. It has been
stated that uric acid is sometimes found in gall-
stones, and, if such were actually the case, we might
infer that a close relation existed between such con-
cretions and gout. Frerichs, however, states that
"uric acid has been found in abundance in a
cylindrical concretion described as a gall-stone, but
there were some doubts as to the place of origin of
this concretion." Stockhardt and Faber some years
ago discovered uric acid in concretions of the same
nature. It must not, however, be forgotten how
readily concretions in collections are confounded with
one another, and wrongly described.* Frerichs thinks

* " Diseases of the Liver," vol. ii, New Syd. Soc. Trans., p. 497.

ALBUMINURIA AND HEPATIC DERANGEMENT. 103

that the co-existence of biliary concretions with
urinary calculi must be regarded as an entirely acci-
dental circumstance. It is certain that no special dia-
thesis is associated with the formation of gall-stones,
for they occur in persons of extremely various consti-
tutions, and more frequently in women than in men.

I now proceed to consider those renal disorders
which are directly due to the gouty dyscrasia, and
I shall first endeavour to trace the influence which
imperfect assimilation and hepatic disorder exercise
upon their development.

The connection between the urinary secretion and
disorder of the functions of the liver is shown by the
frequent occurrence of albuminuria in certain cases of
hepatic derangement. I have noticed this coincidence
in not a few patients, men in middle life, of active
literary habits, but somewhat free livers. These cases
exhibit the ordinary symptoms of gouty dyspepsia, as
already described, but no acute attacks of articular
inflammation ; more or less severe eczema is almost
always complained of. The albumen occurs some-
times in very minute quantities, such as one-tenth per
cent., while in other cases as much as three per cent, is
deposited. No tube-casts are discoverable, and the
albumen disappears in the course of a few weeks

104 ALBUMINURIA AS A SYMPTOM.

under the use of suitable diet, purgatives, and alkaline
treatment. In no cases of this kind should I think it
necessary to prescribe colchicum. I believe that this
appearance of albumen in the urine is due to defective
metamorphosis of nutritive materials by the liver, and
I have little doubt that temporary albuminuria not
unfrequently occurs in the absence of any organic
disease of the kidney.

Not many years ago it was commonly believed that
the occurrence of albumen in the urine was a decisive
proof of the existence of organic disease of the kidneys.
The discovery that albuminuria could be induced by
eating a large number of eggs was sufficient to raise
doubts as to the truth of this view, and we now have
reason to believe not only that albuminuria may occur
in the absence of renal disease, but that traces of
albumen so often occur in normal urine that this
substance may almost be regarded as a regular
constituent of that secretion. Cogent evidence in
support of this latter view has recently been offered
by Professor Senator,* of Berlin. The point is one
of great importance, inasmuch as the discovery of

* " Albuminuria in Health and Disease," New Syd. Soc. Trans.,
p. \$,etseq.

PHYSIOLOGICAL ALBUMINURIA. 105

albumen in the urine naturally gives rise to the
suspicion (and probably often to the conviction) that
the patient is suffering from some form of Bright's
disease. Dr. Senator states that he examined for a
lengthened period and at different hours of the day
the secretion of four persons, all in excellent health,
and at one time or other discovered albumen in the
urine of each, certainly only in faint traces, which
might well have been overlooked had not delicate
tests been employed. "No definite rule governing
its appearance could, however, be discovered ; for the
urine might be examined for several days without
once finding albumen, which would then appear for
a day and again vanish as before." Dr. Senator cites
Leube's* statement to the effect that he found albu-
men in the urine in 19 instances among 119 healthy
soldiers, and also that of Dr. Munn,t who discovered
the same condition in 24 out of 200 apparently healthy
persons who came before him to be examined for
purposes of life-assurance. From these and many
other similar experiences, references to which will
be found in Dr. Senator's treatise, it would appear

* Virchow's " Archiv.," lxxii, S. 145.

t New York Medical Record, March 29, 1879.

106 DIGESTION-ALBUMINURIA.

warrantable to assume that albumen is often present in
normal urine, but only seldom in quantities appreci-
able by ordinary tests. Dr. George Johnson,* however,
while admitting that albuminuria frequently occurs in
persons supposed to be healthy, maintains that even
the occasional presence of the smallest trace of albu-
men is always of pathological import. He alludes to
cases in which some obvious cause could be detected,
e.g., a previous history of acute nephritis, exposure
to cold and wet, as in cold bathing, excessive con-
sumption of food and alcohol, &c. In Dr. Senator's
cases, however, there were no histories of this kind.

It would be foreign to my immediate topic to
discuss at greater length this subject of physiological
albuminuria : I have alluded to it because it is closely
connected with another condition which has been
termed the " albuminuria of digestion," and often
noticed after the use of large quantities of albuminous
food. It is doubtless this form of albuminuria which
is often present in cases of gouty dyspepsia ; some of
the albuminous constituents of the food not being
converted into urea, and passing out of the body in
an unchanged state. The albumen transudes through

* "Latent Albuminuria," British Medical Journal, 1879, v°l« ^
p. 928.

DIGESTI0NALBUM1NURIA. 107

the vessels of the glomeruli, and is not a product of
the secretion of the glandular epithelium. As a
matter of course its presence is most readily detectible
when the urine is scanty and somewhat concentrated,
conditions which frequently obtain in these cases of
gouty dyspepsia. The subjects of this ailment drink,
as a general rule, an insufficient quantity of fluid in
the form of water, the place of which in the economy
cannot be taken by any other liquid. An insufficient
supply of water diminishes the amount of all the
important urinary excreta, but facilitates the appear-
ance of "digestion-albuminuria," and especially when
at the same time meat and other albuminous foods
are taken in excessive quantities. This excretion of
albumen, if of frequent occurrence, is very liable to
cause irritation of the kidneys. Dr. Senator points
out that when egg-albumen as such " finds its way
into the blood, it is excreted by the kidneys ; but fre-
quently this is not all that happens, for, as Lehmann
and Stokvis have observed, more albumen is excreted
than is introduced ; as a matter of course not more
egg-albumen, but a form which possesses the properties
of the ordinary albuminous substances of the serum
(serum-albumin and globulin). It is not improbable
that peptone likewise, and perhaps also hemi-albumose

io8 KIDNEY DISEASE DUE TO MA L ASSIMILATION.

(propeptone), may act in a similar way, i.e., excite
albuminuria."* It is worthy of notice, as corroborat-
ing the views just expressed, that the albuminuria of
Bright's disease is always increased after the use of
animal food.

A consideration of the facts adduced in the preced-
ing paragraphs will, I think, justify the conclusion
that the defective assimilation which exists in gout
may ultimately result in irritation and chronic inflam-
mation of the kidney, and may therefore be regarded
as one cause of Bright's disease. Dr. Murchison has
strongly advocated this view. He states that when
the attack (of acute Bright's disease) follows a chill,
and there is no history of scarlatina, " it will almost
invariably be found that the patients have previously
suffered from derangements of the liver with lithaemia,
while many have led intemperate lives. Again, we
find that functional derangement of the liver resulting
in lithsemia, with dyspeptic symptoms such as those
which I have described, is a common cause of the
contracted, granular, or gouty kidney."

* "On the Hygienic Treatment of Albuminuria," New Syd. Soc.
Trans., p. 143. See also a paper by Drs. Brunton and Power, " On
the Albuminous Substances which occur in Albuminuria," St. Bartholo-
mew's Hospital Reports, 1877.

SIGNIFICANCE OF DIGESTION-ALBUMINURIA. 109

Dr. Dickinson, in the concluding portion of his
excellent work on Renal Disorders, has expressed
the opinion that the albuminuria of dyspepsia is in
all probability indicative of renal mischief. '■' It has
been stated that the urine has become temporarily
albuminous as the consequence only of dyspepsia ;
but, knowing as we do how often inconstant or
periodic albuminuria together with dyspepsia is the
accompaniment of an early stage of the granulating
kidney, particularly when this is connected with gout,
we can but suspect that when the urine has become
albuminous with symptoms of indigestion, the kidneys
may not have been perfectly sound."* With regard to
this opinion, it must be admitted that the discovery
of albumen in the urine is always sufficient to raise
apprehensions of renal lesions ; but, when the quantity
is small and there are no casts, when there are decided
symptoms of gouty dyspepsia, and lastly when the
albumen entirely disappears under proper treatment,
I cannot but think that we are justified in believing
that the kidneys are still sound. If, on the other
hand, the albumen continues, it may not only be
indicative of disease, but, as already mentioned, its

* " On Renal and Urinary Affections," Part III, 1885, PP- 1268-9.

BRIGHT S DISEASE AND GOUT.

passage through the kidneys will serve to intensify
the condition primarily due to its elimination.

I have met with several cases of Bright's disease
in men over fifty, of decidedly gouty tendencies, but
never having suffered from acute gout. Dr. George
Johnson thinks that the granular kidney is often
associated with the gouty diathesis, and "is of
common occurrence in persons who eat and drink to
excess, or who, not being intemperate in food and
drink, suffer from certain forms of dyspepsia without
the complication of gouty paroxysms." After describ-
ing the condition of the urine (which is at first high-
coloured, scanty, and deposits urates, and afterwards
pale, more copious, and albuminous), he goes on to
say, " in such a case probably renal degeneration is
a consequence of the long-continued elimination of
products of faulty digestion through the kidneys."*
Functional disorder of the stomach and liver, as
occurs in gout, may thus result in secondary disturb-
ance of the kidney.

Sufficient evidence has, I think, been adduced in
support of the view that the gouty diathesis is closely

* " Lectures on Bright's Disease," 1873, p. 64. See also the paper by
the same author on " Latent Albuminuria," British Medical Journal,
1879, vol. ii, p. 928.

THE GOUTY KIDNEY.

connected with one form of albuminuria, and this
condition may either subside, leaving the kidneys
sound, or may by its continuance give rise to organic
renal disorder.

I now pass on to consider another form of renal
lesion intimately connected with gout, viz., the gouty
kidney, properly so called. The morbid anatomy of
this condition has been already described (see p. 16).
Of the two principal varieties, one is characterised
mainly by deposits of uric acid and sodium urate
scattered throughout the kidney ; while in the second,
atrophy of the cortical substance and a granular
condition of the kidney (renal cirrhosis) are associated
with these infarctions.

These deposits and the cirrhotic state of the kidneys
are often found in the later stages of gout, but it is
certain that these organs are sometimes affected at an
early period. The irritation due to the excretion of
imperfectly metamorphosed substances may be the
starting-point of a chronic inflammation, even before
any deposit of sodium urate takes place in the kidney,
and it would also seem highly probable that acute
gout sometimes attacks the renal fibrous tissue before
it appears in the joints. Cases of this kind have been
described by Garrod and Charcot. Acute pain in

THE GOUTY KIDNEY.

the lumbar regions and temporary albuminuria pre-
ceding the articular inflammation, are the principal
symptoms ; and it may reasonably be inferred that
these are due to urate-deposits in the tubules and
fibrous tissue.

It must be admitted that some authorities on renal
pathology deny that these urate-deposits are neces-
sarily connected with the gouty dyscrasia, mainly on
the ground that they sometimes occur in the kidneys
of persons who have never exhibited any gouty
manifestations. Experience certainly teaches us that
cirrhosis of the kidney is far from being peculiar to
gout, though it is often found in connection therewith ;
but with regard to these urate-deposits, especially
when found in contracted kidneys, there are strong
grounds for believing, with Dr. Garrod, that they are
nearly always indicative of gouty disorder within the
affected organs. In gout, according to the same
authority, the greater part of the deposit is interstitial ;
in non-gouty cases, the tubular structure is especially
affected, and the crystals of uric acid and sodium
urate are larger, but far less abundantly distributed.
It is worthy of note that contracted kidneys, exhibiting
whitish streaks of sodium urate in the pyramidal
portions, are sometimes found in the bodies of persons

GOUTY KIDNEY.

presenting no external manifestations of gout, but
whose joints, when carefully examined, are found to
be studded over with chalk-like concretions. Dr.
Garrod refers to cases in which these infarctions were
found in the absence of any visible deposits of chalk-
stones, except one or more specks on the cartilage
of the ear. There are likewise strong grounds for
believing that this condition of the kidney is often
present in subjects who have suffered from com-
paratively few attacks of articular gout.

This view of the relation of these infarctions and
the cirrhosed state of the kidney to the gouty
dyscrasia was strongly advocated by the late Dr.
Todd.* In several of his cases the kidneys were
found much contracted and wasted at the expense
of the cortical substance, the cones in some places
reaching almost the very surface of the organ ; " in
some of the cones there were opaque streaks of deposit
of urate of soda taking the direction of the tubes, and
probably occupying the canals of some of them."
Dr. Todd also believed that renal cirrhosis (without
infarctions of urates) is peculiarly apt to be developed

* " Clinical Lectures." Second edition, 1861. Edited by Dr.
Beale. See especially Lecture xxviii on the Gouty Kidney.

T

1 14 SYMPTOMS OF GO UTY KIDNE Y.

in the inveterate gouty diathesis, though it may also
occur in other states of the system.

From the account given in preceding paragraphs of
the state of the kidney often found in connection with
the gouty dyscrasia, it would seem advisable to restrict
the use of the term "gouty kidney" to those cases
in which infarctions of urates are present. The ex-
pression " gouty cirrhosis " should likewise be applied
only to the granular and contracted kidney of gouty
subjects. Renal cirrhosis often occurs independently of
gout, and moreover, in rare instances gout is accom-
panied by amyloid and other changes in the kidney.

I do not think it necessary to describe in any
detail the symptoms of gouty kidney. They are for
the most part those of renal insufficiency. The urine
is generally pale and of low specific gravity, and
contains a diminished amount of urea and salts ; the
albumen is usually small in quantity, and at times
scarcely detectible. Tube-casts, either granular or
hyaline, are always present. The patient is generally
anaemic and gradually loses flesh and strength, and the
symptoms of dyspepsia become aggravated. Sooner
or later there is puffiness of the eyelids, and also slight
cedema of the feet and ankles, observable at first only
at night ; other forms of dropsy, such as ascites and

RELA TION BE TWEEN GRA VEL AND GOUi. 115

hydrothorax, are less common. As the disease
advances, such indications of ill-health as anaemia,
debility, shortness of breath, vomiting, &c, become
more decided, but the progress is often very slow.
Headache and dimness of vision (due to retinitis)
are often present ; symptoms of apoplexy or epilepsy
occasionally supervene, and these signs of uraemia
often usher in a fatal termination. In some cases
they subside and recur from time to time, the
patients feeling comparatively well during the in-
tervals. An unfavourable termination is, however,
always to be looked for, though its advent may
generally be retarded by proper treatment.

I shall conclude this account of gouty affections of
the kidney by referring to the occurrence of gravel,
cystitis, and diabetes in gouty subjects.

Uric acid and urates are frequent deposits in the
urine of gouty persons, and as these substances either
form or enter into the composition of at least seventy-
five per cent, of all calculi, it is reasonable to expect
that the subjects of the gouty dyscrasia would be very
prone to suffer from calculous disorders. As a matter
of fact, gout and calculus sometimes co-exist, and
cases are by no means rare in which persons who in
early life have suffered from stone in the bladder are

I 2

n6 CALCULI AND GOUT.

attacked by gout at later periods. It must not, how-
ever, be inferred that the frequent appearance of uric
acid and urates invariably presages the formation of
a calculus, for many persons void these substances
for lengthened periods, and -yet never suffer from
stone. I often meet with instances of this kind
among persons hereditarily predisposed to gout. The
form which the crystals take probably influences the
formation of calculi ; spiny clumps of uric acid are
the most potent in this respect T)r. Ord thinks that
no calculus is formed of oxalates, urates and uric acid,
or phosphates, without the intervention o some colloid
substance, and that the most active matters in forming
calculi are the exudation from the tubes and the
mucus from the urinary tracts. The question of the
origination of calculi* has not as yet been fully solved,
and it would be foreign to my present purpose to
discuss it any further ; T would just remark, however,
that calculi of oxalate of lime, or containing layers of
this substance, are sometimes found in gouty subjects.
I have at present under my care a lady, aged fifty-
six, who has frequent attacks of gout, and occasionally

* For an exhaustive account of the latest views on this subject, see
Dr. Dickinson's work on " Renal and Urinary Affections," Part III,
p. 860, et seq.

BLADDER-SYMPTOMS AND GOUT. 117

passes small calculi of oxalate of lime. With regard
to phosphatic calculi, these of course have no con-
nection with gout, but are for the most part secondary
formations due to decomposition of the urine.

Irritability of the bladder is a common symptom
in gouty subjects, and is generally accompanied by
scanty and highly acid urine, depositing uric acid and
urates. Sometimes the irritability is attended, by
increased secretion from the mucous membrane of the
urethra and burning pain in this part; and these
symptoms occur in some persons shortly before an
attack of gout. In other cases the vesical irritation
accompanies the paroxysm ; while in ai third class the
irritability is relieved or suspended on the outbreak
of an acute attack.* Dr. Todd| has recorded a case
in which vesical irritation rapidly supervened after
an incision had been made into a gouty foot. He
has also described cases of spasm and paralysis of
the bladder in gouty subjects.

It would also appear that inflammation of the
mucous membrane of the bladder may be due to gout.

* See Coulson on "Diseases of the Bladder and Prostate Gland,"
sixth edition, p. 254.

f "Clinical Lectures," second edition, p. 563.

1 1 8 GOUT AND DIABE TES.

Sir James Paget* states that gouty cystitis may present
all the ordinary characters of acute inflammation of
the bladder from any other cause. Its gouty origin
may be suspected if it has begun suddenly and after
the use of indigestible food, or if it has been preceded
by excess of urates in the urine. In some cases
cystitis has been known to supervene on the dis-
appearance of an eczematous eruption ; Sir James
Paget thinks that acute eczema of the mucous mem-
brane of the bladder exists in such cases.

A close connection can sometimes be traced between
diabetes and gout. In cases of gouty dyspepsia, the
urine frequently contains traces of sugar, and among
the sufferers from articular gout, diabetes occasionally
supervenes and takes the place of the previous dis-
order, which is apt to recur when the amount of sugar
and the quantity of urine become lessened. The two
disorders may, however, co-exist. Diabetes occurring
in gouty subjects is more amenable to treatment than
when this latter dyscrasia is absent. Members of
gouty families would seem to be peculiarly liable to
diabetes ; in some of these cases, regular gouty attacks
come on, in others there are only slight symptoms.

* " Clinical Lectures and Essays," second edition, p. 377.

GO UT AND DIABE TES. 1 1 9

Charcot states that the children of diabetic subjects
are predisposed to gout, and cites a remarkable
instance of this nature. He mentions also another
family in which the father was gouty, while gravel,
diabetes, gout, and phthisis occurred among the
children. The advocates of the neurotic origin of
gout cite the frequent connection between the gouty
dyscrasia and glycosuria as evidence in support of
their views.

20

CHAPTER VII.

THE TREATMENT OF GOUT AND OF VARIOUS
DISORDERS CONNECTED WITH IT.

The Treatment of the Gouty Diathesis — Evidence that
the Gouty Diathesis may be Modified or Removed —
Objects to be aimed at in the Treatment — Question of
Diet for Gouty Subjects — Animal Food — Drawbacks
attending excessive use of vegetable food — quantity
of Meat to be allowed — Other articles of food — Acids
to be avoided — farinaceous food — alcohol — mllk —
Tea, Coffee, and Cocoa — Articles of Diet suitable for
Gouty subjects — Question as to Gelatine — Quantity of
Food — Importance of Diet-Rules — Printed Forms
desirable — production of sense of satiety to be
avoided — Exercise for Gouty subjects — Horse Exercise
— Walking — Passive Movements — The Zander Method —
Fresh Air — Good influence of Sea Air — Mountain Air
— Condition of Liver and Stomach — Action of Saline
Purgatives — Various Mineral Purgative Waters,
Friedrichshall, Pullna, &c. — Carlsbad Salts — Other
Purgatives and Hepatic Stimulants — Alkalies — Mineral
Waters of Bath, Buxton, Wildbad, Teplitz, Vichy,
Baden, Wiesbaden, Aix-la-Chapelle, and Aix-les-Bains —
Efficacy of Water as a Drink for Gouty subjects^
The simple Thermal Waters — Alkaline Waters —
Muriated Saline Waters — Turkish Baths — Avoidance
of Excitement and a proper amount of rest necessary
for Gouty subjects — The Treatment of an Acute
Attack of Gout — Purgatives — Alkalies — Colchicum —

TREATMENT OF THE GOUTY DIATHESIS. 121

Belladonna as a Local Application — Diet and Regimen
— Treatment during the intervals — Iodide of Potassium
— Alkalies — Mineral Waters — Guaiacum — Tonics as Iron,
Quinine, &c. — Local Treatment in Chronic Gout —
Chalk-stones and Gouty Ulcers — Treatment of Gouty
Disorders of the Liver and Kidneys and of Gouty
Cutaneous Affections.

I PROPOSE in this, the concluding chapter of my work,
to describe the treatment, first, of the gouty diathesis ;
secondly, of an acute attack of articular gout ; and
thirdly, of the more important of those disorders
which are the direct results of the gouty dyscrasia.

I. The Treatment of the Gouty Diathesis. — Experience
teaches us that the gouty diathesis may be decidedly
modified or even altogether removed, and that these
objects can be effected even after several acute attacks
have actually occurred. The case of the late Dr.
Gregory, of Edinburgh, has been often cited in proof
of this assertion. Dr. Gregory was descended from
a decidedly gouty family ; before he was thirty years
of age he had had several severe attacks of acute gout,
and occasional gastric spasms due to the same cause.
By taking active exercise, avoiding all excesses, and
keeping to a strictly moderate diet (although he did
not abstain from animal food) during a period of
twenty years, he so completely overcame the disposi-

122 TREATMENT OF THE GOUTY DIATHESIS.

tion to the disease that all symptoms of it disappeared
in the latter part of his life. Dr. Todd, in referring
to the above case, very justly remarks that "there
is no disease in which the patient can do so much
for himself, or in which the prescriptions of the
physician are of so little avail without the full and
complete co-operation of the patient, as in gout.*

Sufficient evidence has already been adduced in
support of the view I have adopted as to the nature
and cause of the gouty diathesis, viz., that excessive
formation of uric acid is the condition which underlies
gouty manifestations of all kinds. It follows that for
the rational treatment of this diathesis our object
should be to check the production of this materies
morbi and to promote its elimination from the system.
The attainment of these ends is the problem to be
solved.

It has been shown in preceding chapters that ex-
cessive formation of uric acid and its accumulation
in the blood are for the most part due to defective
metamorphosis of the albuminous elements of food,
and that the liver is the organ which is mainly at
fault. In order, therefore, to combat the symptoms of

* " On Gout and Rheumatism," p. TJ.

DIET FOR GOUTY SUBJECTS. 123

the uric acid diathesis, the diet and the condition of
the liver are the first subjects which require attention.

With regard to the diet, an all-important subject in
the treatment of any form of gout, I propose only to
lay down a few general principles, because in dealing
with this disease it is absolutely necessary to make
a special study of each patient. Certain maxims,
however, apply with greater or less force to all cases.
The primary indication is to supply a sufficient
amount of those albuminous substances which are
readily utilised and metamorphosed in the system.

A certain proportion of albuminous constituents is
necessary for the wants of the organism, and those
systems of treatment which are based upon almost
complete abstinence from animal food have never
been found serviceable for gouty cases. Vegetable
food in quantity sufficient to contain the requisite
amount of albumen will furnish at the same time an
excessive proportion of carbo-hydrates, which being
more easily oxidised, and therefore more readily
consumed in the system than the albuminous com-
pounds, will, to a considerable extent, spare or prevent
the disintegration and oxidation of the latter. It is
moreover probable that vegetable albumen less readily
undergoes disintegration than albumen of animal

124 DIET FOR GOUTY SUBJECTS.

origin. In gout the disintegrative changes in the
albuminates are arrested, and insufficiently oxidised
substances remain in the blood. Under ordinary
circumstances, when a diet is taken in which animal
food preponderates, a larger amount of oxygen is
retained in the system than when amylaceous food
s in excess.

The result of the above considerations would appear
to be that meat is not to be forbidden to gouty patients ;
though, as a matter of course, certain restrictions
must be laid down as to its use. The following are
the chief points to be attended to in connection with
the diet : —

1. The quantity of the meat to be allowed.

2. The quantity and quality of other articles of food

usually taken with meat, and which lessen or pre-
vent the oxidation of albuminous substances.

3. The avoidance of acids and of acid-forming

substances, the operation of which is to diminish

the alkalinity of the blood and juices of the

tissues, and thus to favour the precipitation of

the urates and their retention in the system.

The quantity of meat and of albuminates in general

to be allowed to subjects of the uric acid diathesis

should be in strict proportion to the wants of the

FARINA CE 0 US FO OD—AL COHOL. 1 2 5

system, and this limitation should never be exceeded.
Physiology teaches us that about twelve ounces of
meat and two pounds of bread are amply sufficient to
compensate the daily losses of the system of a healthy
man. For gouty subjects a far smaller proportion of
carbo-hydrates is advisable, and of these latter sub-
stances, sugar and starch, having a greater affinity for
oxygen, would appear to be even more prejudicial
than fat.

For the reasons above given, farinaceous food, such
as bread, rice, potatoes, &c, should be used very
sparingly ; pastry of all kinds should be strictly for-
bidden. A little fruit may be allowed, provided that
no undue amount of acid or of saccharine materials is
thereby introduced into the system. Both theory and
experience teach us that alcohol in any form should
be avoided by gouty subjects ; it undergoes oxidation
in the system and checks metamorphosis. Plain pure
water, aerated water, or some of the alkaline acidulous
waters, form the best fluids for gouty subjects. In
cases, however, in which the digestion is feeble, a
small quantity of alcohol is sometimes beneficial.
Old whisky or brandy is probably the least injurious
form of alcoholic stimulant ; a tablespoonful diluted
with six ounces of water should be the maximum

126 MILK-DIET FOR GOUTY SUBJECTS.

quantity allowed. If wine be preferred, sound claret
and hock are best suited for gouty patients. One,
two, or even three wineglassfuls may be permitted
according to circumstances. Imperfectly fermented
and effervescing wines, and malt liquors of all kinds,
should be strictly forbidden. Acids and all substances
likely to undergo acid fermentation must be inter-
dicted. Acids when absorbed into the blood lessen
its alkalinity, inasmuch as they combine with the
alkalies they meet with, and set free weaker acids.
With the object of preventing scorbutic symptoms,
I sometimes allow gouty persons, for whom vegetables
would be injurious, to take a little lime-juice, well
diluted with water.

There is some difference of opinion with regard to
the effect upon gouty subjects of a diet composed
largely of milk. When large quantities of milk are
taken, the general result is an increased production of
uric acid, and this fluid would therefore appear to be
unsuitable for such patients. Experience, however,
shows that some gouty subjects can take one or two
pints of milk in the twenty-four hours with apparent
benefit. The prejudicial effects of milk would appear
to be due to the lactic acid which results from the
fermentation of the milk sugar. It is worthy of note

DIET FOR GOUTY SUBJECTS. 127

that the administration of lactic acid to gouty subjects
causes the attacks to become not only more frequent,
but also more severe and obstinate. Moderation
should be observed in the use of tea and coffee ; the
former especially should be avoided whenever flatulent
dyspepsia is a prominent symptom. Cocoa is often
preferable for these patients. The nibs should be
coarsely powdered and boiled for two or three hours ;
the liquor is then strained, and the fat, which rises to
the surface, removed when cold.

From what has been just stated it will be evident
that only a few articles of diet can be safely re-
commended to the subjects of the uric acid diathesis.
Mutton, beef, chicken, game, fish, eggs, and green
vegetables (including cress, lettuce, &c), constitute
the list of articles from which a selection must be
made. A few ounces of stale bread and a small
quantity of butter may be allowed. A diet thus
restricted will furnish the necessary amount of albu-
minates, and the articles are easy of digestion and
not likely to set up acid fermentation in the stomach.
Substances containing much gelatine should be
avoided. Gelatine when introduced into the sys-
tem appears to undergo a decomposition analogous
to that of the albuminous compounds ; the ingestion

128 DIET- RULES FOR GOUTY SUBJECTS.

of large quantities is followed by a marked increase
in the proportion of urea in the urine, with decided
elevation of the specific gravity. In non-gouty sub-
jects the uric acid is not increased in quantity,
but it is probable that where metamorphosis is
imperfect, other substances, and uric acid among
the number, would be formed in place of urea.

It is not sufficient to lay down rules as to the
quality of the food ; the quantity is a point of no less
importance. I have for some time past been in the
habit of supplying my patients with printed "diet-
rules." I keep at hand a set of forms on which the
hours for meals, and the articles that may be taken
and those that must be avoided, are clearly specified.
As a matter of course, modifications, by way of
addition or subtraction, are sometimes required, and
spaces are therefore left for additions. I attach the
greatest importance to these diet-rules ; a patient is
far more likely to obey instructions contained in
a printed form than verbal directions, however em-
phatically expressed. To the list of articles I have
appended a caution with regard to the ill effects
of rapid eating. Gouty patients, above all others,
should exercise great moderation in the quantity of
food taken at each meal. A positive sense of satiety

EXERCISE FOR GOUTY SUBJECTS. 129

should not be experienced, for, as justly remarked by
Dr. Beaumont, "this is beyond the point of healthful
indulgence, and is Nature's earliest indication of an
abuse and over-burden of her powers to replenish the
system." That which ought to be attained " occurs
immediately previous to this, and may be known by the
pleasurable sensations of perfect satisfaction, ease, and
quiescence of body and mind. It is when the stomach
says, enough; and it is distinguished from satiety by the
difference of sensations — the latter saying too much"
When, as not unfrequently happens, corpulence is as-
sociated with gout, the quantity of all articles of diet
must be uniformly reduced ; that of the albuminous
kinds should be considerably diminished, for no one
becomes corpulent without taking albumen, in some
form or other, in excess of the requirements.

Exercise and abundance of fresh pure air come
next to diet in the treatment of the gouty diathesis.
Exercise promotes tissue-change and the oxidation
of the constituents of the body, and many a gouty
patient of lazy, indolent habits would get rid of his
complaint if he were to become a farm labourer or
a postman. Walking exercise for several hours a
day should, whenever possible, be enjoined. Horse
exercise, "the Palmerstonian cure for gout," as one

K

130 EXERCISE FOR GOUTY SUBJECTS.

German writer terms it, is also very advantageous,
and should be tried whenever circumstances will
admit. Muscular exercise promotes the consumption
to some extent of albuminates, and to a far greater
degree of glycogen and sugar. Mental activity in
moderation is also desirable, for it too promotes
tissue-change. When patients are unable to take
active exercise by reason of gouty deposits, stiffness,
and pain in the joints, some forms of passive move-
ment, with friction, shampooing, &c, should be
recommended. Dr. Zander, of Stockholm, has in-
vented a series of machines by means of which the
several muscles of the body can be brought into play,
and thus a considerable amount of exercise can be
taken without undue fatigue. Shampooing machines
for the legs and abdomen, and friction machines for
the hands and feet, are also to be found at the Zander
Institute.* The amount of exercise, whether natural
or artificial, must be carefully adapted to the circum-
stances of the case ; anything approaching to undue
fatigue must be avoided. Acute attacks may not

* For details of Dr. Zander's system the reader is referred to a little
work entitled " Mechanical Exercise a Means of Cure," being a
description of the Zander Institute, London, its History, Appliances,
&c, London : J. & A. Churchill. 1883.

EXERCISE AND FRESH AIR. 131

unfrequently be traced to over-exertion. In connec-
tion with this subject it must be kept in mind that a
certain interval should always elapse between exercise
and meals. Over-fatigue is a fertile source of indiges-
tion, and to sit down to a meal immediately after
exercise is not conducive to normal digestion.

Fresh air is especially indicated for gouty subjects ;
but exposure to damp and cold should be carefully
avoided. Sea-air often causes a marked improve-
ment in these cases, and should always be tried. It
promotes in an especial manner the oxidation and
transformation of albuminous tissues. The bracing
air of mountainous districts is beneficial for many
patients ; on the other hand, cases of confirmed gout
often require a considerable amount of warmth.

Attention to the functions of the skin is all-impor-
tant for gouty subjects. I shall have more to say on
this subject when describing the various baths that
may be used.

In gouty subjects the condition of the stomach and
liver, and of the whole intestinal tract, is second in
importance only to the question of diet. I have
already explained that frequent deposits of uric acid
and urates in the urine are generally due to hepatic
derangement, for the relief of which it is useless to

K 2

132 PURGATIVES SUITABLE FOR GOUTY SUBJECTS.

prescribe merely alkalies and diuretics, remedies
which aid the elimination of uric acid, but do not
prevent its formation. Various medicines act more
or less decidedly upon the liver, and in cases of
functional derangement purgatives are very useful.
Saline aperients are those which are generally indi-
cated. They act promptly, and not only remove the
contents of the bowels, but cause a decided drain
from the intestinal vessels and relieve any congestion
which exists in the portal system. Opinions differ
as to the way in which these medicines produce their
purgative effect. Liebig's theory was that an osmotic
current takes place from instead of towards the
circulatory system. Active purgation, however, may
be produced in animals by injecting certain saline
solutions into the veins. It would appear more
probable that these solutions act by preventing the
absorption of the secretions which are constantly
poured out from the mucous membrane of the
intestine, and are taken up by the veins and lym-
phatics. The salts best adapted for cases of lithaemia
are the sulphates of soda and magnesia (the latter
I often prescribe in combination with sulphate of
quinia), the phosphate of soda and the tartarated
soda. These may be given in the ordinary manner,

PURGATIVES SUITABLE FOR GOUTY SUBJECTS. 133

but for many cases the best way of exhibiting them
is in the form of some one or other of such mineral
waters as Friedrichshall, Piillna, Kissingen, ^Esculap,
or Hunyadi Yanos. The dose must be regulated
according to the circumstances of the case ; from two
to five or six fluid ounces may be required. It is
generally advisable to add an equal quantity of hot
water, and the medicine should be taken about half-
an-hour before breakfast. The quantity should be
sufficient to produce one or two evacuations without
griping or much discomfort.

When symptoms of gastric catarrh, fermentation,
and acidity exist, Carlsbad water is preferable. The
principal salts contained in the water of the Sprudel
spring at Carlsbad are the sulphate and carbonate of
soda and chloride of sodium. Carlsbad salts obtained
by evaporating the water can be procured in the
solid form, and when dissolved in a suitable quantity
of water are very efficacious. About a teaspoonful
should be dissolved in half a pint of boiling water, and
when the solution has cooled down to about 1200, two
or three ounces should be taken every five minutes.
This treatment may be continued for several weeks, if
necessary ; the solution being taken every morning or
every other morning, according to circumstances. The

1 34 HEP A TIC AL TERA TIVES.

quantity of the salt should be increased if the bowels
are not sufficiently acted upon ; or a small dose (gr. j.)
of the extract of aloes may be taken before dinner.

Other purgatives and certain hepatic alteratives
are often useful in the treatment of the uric acid
diathesis. Small doses of calomel or blue pill, either
alone or combined with colocynth or rhubarb, may
be given from time to time. When there is marked
congestion of the liver a full dose of calomel (three or
four grains), followed after two hours by an ounce of
Mist. Sennse Co., or a few ounces of one of the saline
waters, will be the best plan of treatment. Various
other hepatic stimulants, as podophyllin, euonymin,
iridin, and leptandrin, are available for use in chronic
cases. Deposits of oxalate of lime are often found
associated with lithates, and when this condition
exists the nitro-muriatic acid combined with the
tincture of nux vomica and henbane, and taken before
meals, will often cause both forms of deposit to
disappear from the urine. As a general rule, acids
are contra-indicated in gouty cases, but where chronic
congestion and torpor of the liver exist, a course of
nitro-muriatic acid is almost always beneficial. When
the urine contains much free uric acid, and exhibits a
marked acid reaction, alkalies are generally indicated,

MINERAL WATERS. ' 135

and of these some preparation of potash or lithia is to
be preferred. The alkalies facilitate the elimination
of uric acid, but, unlike remedies which promote the
hepatic functions, they do not prevent its formation.*
The citrate of potash is a convenient preparation :
a few doses ordinarily suffice to diminish the acidity
of the urine.

In addition to those which are more or less pur-
gative in their action, certain mineral waters have
a widespread reputation in the treatment of the
gouty diathesis. Among the most celebrated are the
waters of Bath and Buxton in this country, and of
Wildbad, Teplitz, Vichy, Baden, Wiesbaden, Aix-la-
Chapelle, and Aix-les-Bains on the continent. The
first four are simple thermal waters — that is, their
natural temperature is high, but they contain only
small proportions of mineral matters. The waters of
Vichy are decidedly alkaline owing to the presence
of carbonate of soda ; those of Baden and Wiesbaden
belong to the muriated saline class, chloride of
sodium being the principal saline constituent. The

* Dr. Murchison attributes to alkalies the power of combating the
pathological condition which leads to the undue formation of lithic acid.
He regards them as promoters of oxidation and disintegration of tissue.
It is, however, by no means certain that alkalies {e.g., liquor potassae)
increase the amount of urea in the urine.

136 MINERAL WATERS AND BATHS.

springs of Aix-la-Chapelle and Aix-les-Bains yield
water containing sulphuretted hydrogen. The water
of the former place contains also a marked quantity
of common salt. All these waters are taken inter-
nally and also used for baths.

There can be no doubt as to the efficacy of water
as a drink for gouty subjects, and as it is generally
difficult to persuade people to make use of what is
close at hand, it is often expedient to advise a journey
and a stay for several weeks at some one or other of
these baths. The action of the simple thermal or
indifferent waters is neither greater nor less than that
of any ordinary pure water heated to the requisite
degree. Water taken internally washes out the
stomach, augments secretion, promotes the trans-
formation of tissue, removes waste products from the
blood, and thus fulfils many of the indications for the
treatment of gout. Hot water, especially if taken
slowly, is rapidly absorbed by the blood-vessels, and
is tolerated without difficulty by the stomach.

When used as baths, the simple thermal waters
produce effects similar to those of ordinary warm
baths, and depending mainly on the temperature
of the water, and the time spent in the bath. The
skin is softened and cleansed, its circulation is

MINERAL WATERS AND BATHS. 137

accelerated, and on leaving the bath the action of
the cutaneous glands is considerably heightened.

The simple alkaline waters, as those of Vichy, have
an antacid and diuretic effect, and their internal
use serves to render uric acid more soluble and thus
promotes its elimination. It is doubtful whether
any saline matters are absorbed when these waters
are used for baths. Some observers state that the
urine becomes alkaline after a bath of Vichy water.
The same result, however, has been noticed after
an ordinary warm bath, and is probably due to the
fact that an increased amount of acid leaves the
system through the cutaneous perspiration.

The use of the muriated saline waters (which
contain chloride of sodium) promotes tissue-change,
checks acid fermentation, and accelerates the osmotic
circulation in the bowels. When used as baths, these
waters stimulate the skin and improve its nutrition.
It is difficult to believe that any definitely good
effects can result from the sulphur waters.

As remedies for gout, little if any permanent benefit
can be expected to arise from the mere use of any of
the above-mentioned waters, though they are often
valuable adjuvants to more rational plans of treat-
ment. A course at such places as Vichy, Bath,

138 MINERAL WATERS AND BATHS.

or Buxton, will no doubt relieve many of the
symptoms, but the improvement will be only of a
temporary character. On the other hand, permanent
good is likely to result from the internal use of those
waters which contain the sulphates and chlorides and
a small proportion of the alkalies. These waters are
especially indicated in cases in which abundant forma-
tion of uric acid is associated with corpulence and
signs of plethora. For weakly persons their occasional
use will often prove beneficial, but a course of the
muriated alkaline waters or of the simple thermal
waters is generally more suitable. One advantage
connected with a course of treatment by baths and
waters is due to the fact that, while it is going on,
patients are generally very careful in obeying all
directions with regard to diet and regimen. In
some cases the good habits thus acquired become
permanent. Equal results might doubtless be 'very
often obtained under similar treatment and regimen
at home ; but such a method fails to commend itself
to most people by reason of its simplicity and the
comparative facility with which it might be carried
out.

After a bath of any kind, the skin should be
thoroughly dried and well rubbed with a coarse towel.

ATTENTION TO THE SKIN, REST, ETC. 139

The use of a flesh-brush is also very advantageous.
Turkish baths are not suitable for the majority of
gouty subjects ; they are sometimes useful for young
and plethoric persons with rough and coarse skins
and deficient perspiration. They are also beneficial
in a small number of chronic cases, provided that
there is no cardiac complication. They should not
be too frequently taken, as they are apt to cause
debility.

Avoidance of undue excitement and a proper
amount of rest are the last points to which I shail
refer in connection with the hygiene of the gouty
dyscrasia. Nervous exhaustion, from any cause, much
intensifies the action of the other factors of gout, and
all possible care should therefore be taken to prevent
its occurrence. Late hours are especially injurious,
and the patient's habits as regards sleep should always
be inquired into. Too little sleep is as mischievous as
too much ; it is a fertile source of nervous exhaustion.
In all cases of sleeplessness, the physician should direct
his attention to the condition of the stomach, liver,
and kidneys : he will often find that the discomfort
is due to functional disorder of some one or all of
these organs.

I shall add a few more remarks on the medicines

140 THE TREATMENT OF ACUTE GOUT.

suitable for gouty subjects after a brief description
of the treatment of an ordinary acute attack.

II. The Treatment of an Acute Attack of Articular
Gout. — When called to a patient suffering from an
acute attack, I invariably examine the urine for
albumen. If this latter be absent, and if there be
constipation and signs of congestion of the liver, two
or three grains of calomel, followed by a draught
containing sulphate and carbonate of magnesia, may
be prescribed with advantage. If there be no marked
evidence of hepatic congestion, milder remedies will
suffice to relieve any constipation that may be present.
The saline draught alone, or ten grains of Pil. Colo-
cynth. et Hyoscyami, with perhaps a grain of calomel
or a quarter of a grain of Resin. Podophylli will
generally produce a free action of the bowels. At
the same time I prescribe a mixture with Vin.
Colchici tn. x., and grs. x. — xx. of some alkaline
salt, such as the bicarbonate of potash or soda, the
carbonate of magnesia, or the citrate of magnesia
or potash. This should be taken four times in the
twenty-four hours, and continued according to cir-
cumstances. If there be much fever, Liq. Ammon.
Acetat. 3ij. may be added to each dose.

For the relief of the pain I find great benefit from

THE TREA TMENT OF AC UTE GOUT. 141

the local application of belladonna in the following
form: — R. Extract. Belladonnse 31J., Glycerini gss.,
Aquae 51J. A sufficient quantity of this mixture is
placed upon cotton wool and applied to the affected
joint, which should be raised upon a pillow and
kept in the position most conducive to the patient's
comfort. As a matter of course, while active sym-
ptoms continue, the patient should be restricted to
such articles of diet as arrowroot, sago, gruel, milk
puddings, &c. Seltzer, Apollinaris, or other aerated
alkaline water may be freely allowed. When the
acute symptoms have subsided, beef-tea, fish, and
chicken may be taken in small quantities ; the return
to ordinary diet should be very gradually effected.
Rest and care are essential for some days after the
subsidence of the paroxysm. The application of
leeches, blisters, or cold in any form to the affected
joint is always to be deprecated. Cold applica-
tions, indeed, are highly dangerous (see p. 79).

With regard to the use of colchicum in gout, this
drug has been proved not to increase the elimina-
tion of uric acid, and there is no evidence of lessened
formation of this substance under its use. On the
other hand, it certainly exerts a specific influence on
gouty pain and inflammation, and the results are clearly

1 42 TREATMENT DURING THE INTERVALS.

not due to its action as a purgative or a sedative. I
prefer to use it in small doses (n\ x. — xv. of the Vinum
Colchici) at intervals of four or six hours. It is
sometimes useful in chronic gout, but far less
frequently than in the acute attacks. For weakly
subjects, colchicum is almost always contra-indicated.
When aperients are required, I sometimes order
small doses of the acetous extract in combination
with colocynth and henbane.

In the intervals between the paroxysms much may
be done to prevent recurrences, proper diet and
regimen being far more efficacious in this respect
than any form of medicine. The directions already
laid down with regard to food, fresh air, exercise,
attention to the functions of the skin, bowels, &c,
should be fully explained to the patient, and he
should be warned that if these are neglected, neither
drugs nor mineral waters will prove of any avail.
Provided that due attention be paid to these sub-
jects, various medicines will help to combat the
gouty tendencies and to prevent further attacks, or
at least to diminish their frequency and severity.

Iodide of potassium is often serviceable for these
purposes ; it is of course especially indicated when-
ever gout is complicated by lead-poisoning. Its

ALKALIES, TONICS, ETC. 143

good effects are often well marked in other cases ; it
may be advantageously combined with bicarbonate of
potash in some bitter infusion. Various alkaline re-
medies are generally useful, their main action being
to facilitate the excretion of uric acid. Potash and
lithia are the alkalies which form the most soluble salts
with uric acid. These should be given for lengthened
periods (four to eight weeks) in small doses, and
in very dilute solutions. The mineral waters, already
mentioned, may be substituted for these simpler
methods of exhibiting the drugs. The ammoniated
tincture of guaiacum is a very valuable remedy in
many cases of chronic gout. This drug stimulates
the action of the skin and kidneys ; it is especially
adapted for chronic atonic cases. If thought desirable,
the iodide of potassium and the bicarbonate of potash
may be given in combination with it. Guaiacum
should not be given when there are any decided
inflammatory symptoms.

Various tonics and stomachics are often required for
gouty subjects. Iron is almost always useful when-
ever there is marked anaemia. I generally prescribe
the tincture of the acetate for such cases. The state
of the bowels should always be attended to when
iron is being administered. An atonic condition of

144 LOCAL TREATMENT OF GOUT.

the stomach may be improved by quinine and other
bitters. Quinine is also valuable in checking fer-
mentation in the stomach and intestines.

With regard to the local treatment in chronic gout
affecting the joints, the application of the tincture of
iodine generally affords the most relief to pain and
swelling ; mercurial plasters may also be tried. Gentle
friction with various liniments, and carefully applied
pressure by means of bandages, are often beneficial.
The bandages should not, however, be continuously
applied ; on the other hand, movement should be
encouraged from time to time. CEdema of the limbs
may be relieved by friction, warm douches, bandages,
and the adoption of an elevated position. It is
connected sometimes with phlebitis and sometimes
with renal disease, and in either case is apt to be very
troublesome. Chalk-stones, when prominent, should
be protected from injury. Much good may be done
by the continuous application of alkaline solutions,
and especially of a solution of carbonate of lithia
v'grs. v. to gj.), as recommended by Dr. Garrod. A
piece of lint is soaked in this fluid, and applied to the
joint and then covered with oiled silk or gutta-
percha tissue. The addition of an equal quantity of
iodide of potassium increases the efficacy of the

TREA TMENT OF HEP A TIC S YMPTOMS. 1 45

solution, especially when there is much inflammatory
thickening round the joint. Under similar circum-
stances, warm douches, passive movements, sham-
pooing, &c, are likely to be serviceable. The
removal of chalk-stones, through incisions into the
skin, is fraught with danger ; erysipelas is very likely
to supervene. Gouty abscesses may be very carefully
punctured : if ulcers form, they should be protected
from injury, and treated in the ordinary way.

III. The Treatment of Gouty Disorders of the
Liver and Kidneys and of Gouty Cutaneous Affec-
tions.— Gouty inflammation of the biliary ducts
should be treated by poultices to the abdomen
and warm baths, with a little blue pill and the sul-
phate of soda or magnesia as a purgative. Alkalies,
such as the citrate or bicarbonate of potash, are
afterwards indicated. The affection of the biliary
ducts is generally preceded by catarrh of the
stomach and duodenum. The diet must be carefully
regulated.

Gouty dyspepsia is best treated by mild purgatives,
such as the Carlsbad salts, and by effervescing alkaline
mixtures. With regard to diet, meat should be
allowed only once daily, and alcoholic liquids, sugar,
and starchy articles of food should be forbidden.

L

146 TREATMENT OF GOUTY

The hygienic treatment of the uric acid diathesis
must of course be followed out.

Cirrhosis of the liver occurring in gouty subjects
requires the ordinary treatment. With regard to
diet, it is not enough to prohibit the use of alcohol,
inasmuch as in all probability the disease is some-
times due to the action upon the liver of other
irritants, such as ill-digested food, &c.

In the treatment of gouty disorder of the kidneys,
the urine should be carefully examined for albumen,
tube-casts, and sugar. If the secretion be found
normal in these respects, any symptoms referable to
the kidneys, such as pain in the loins, frequent mic-
turition, and a highly concentrated and acid state of
the urine, will be best treated by saline purgatives,
followed by citrate of potash in an effervescing solu-
tion. Warm baths, warm fomentations, or mustard
plasters to the loins will relieve the pain, and any
renal congestion that may be present.

If the urine contains albumen, but no casts, the
significance of the albumen is the question to be
decided. As mentioned in a previous chapter (see
p. 46) albuminuria of this kind not unfrequently
co-exists with symptoms of gouty dyspepsia, and is
due, I believe, to malassimilation of food. It subsides

AFFECTIONS OF THE KIDNEYS. 147

under the treatment already indicated ; but it must
not on that account be regarded as an unimportant
symptom, for if neglected it may set up serious
disease of the kidneys.

If the albuminuria recur from time to time in a
gouty subject, and if casts of the tubes appear, there
can be no doubt as to the existence of a renal lesion.
The albumen may be in very small quantities, and
at times even absent ; the casts are either hyaline
or granular. Other symptoms, already described,
gradually supervene, and the disease generally runs
a protracted course.

The treatment is that of the cirrhotic form of
Bright's disease ; special attention must of course be
paid to the dyscrasia to which the renal affection is
due. The measures recommended for dealing with
the gouty dyscrasia and for chronic gout must be
rigorously enforced. Suitable diet, exercise short of
fatigue, a proper amount of rest, attention to the state
of the bowels, and to that of the skin, will tend to
delay the advent of untoward symptoms. Counter-
irritation to the kidneys and hot air baths or vapour
baths are valuable remedies in this class of cases.
Alkalies are generally indicated, but should be used
with caution in cases in which the eliminating powers

L 2

148 TREATMENT OF GOUTY ECZEMA.

of the kidneys are defective. Iodide of potassium is
sometimes useful, and should always be given when
lead-poisoning is suspected. Opium in any form is
of course quite out of place. Patients with this
condition of the kidneys are peculiarly susceptible to
the action of this drug. When the disease is well
marked, a nourishing diet and iron are generally
indicated. Warmth and rest of body and mind are
absolutely essential.

The treatment of gouty cutaneous affections can be
summed up in a few words. Eczema and psoriasis
always require constitutional remedies ; the local
treatment is of subordinate importance. The diet
and regimen should be carefully attended to ; over-
indulgence in animal food should be strictly prohibited,
and any co-existing dyspepsia must be dealt with
as already described. When the skin-affection is
associated with plethora, saline purgatives and alkalies
are indicated ; when there is debility, the digestion
should be aided by vegetable bitters and other tonics.
Remedies which stimulate the hepatic functions are
generally serviceable. The action of the skin should
be promoted by vapour baths or hot air baths. Arsenic
may be tried should the skin-affection prove very
obstinate. As local remedies, in the early stage of

TREATMENT OF GOUTY ECZEMA. 149

eczema, a lotion containing bromide of potassium
grs. xv. to 5J.) will often relieve the itching ; in later)
stages, the white precipitate ointment, zinc ointment,
and various preparations of tar are likely to be
serviceable. It must be borne in mind that eczema
in gouty subjects is very apt to recur, especially in
the spring of the year.

INDEX.

A.

Abscesses, gouty, due to chalk-stones, 14.

Acidity of stomach, causes of, 67 ; of urine, relation of uric acid to,

26.
Acids, avoidance of, in the treatment of gouty subjects, 124.
Acute gout, treatment of, 140.
Age in relation to gout, 60.
Albuminuria in gouty dyspepsia, 46, 1 03 ; in gouty subjects, 16; of

digestion, 106 ; physiological, 104.
Alcoholic liquors as a cause of gout, 68.
Alkalies in the treatment of gout, 134, 143.
Angina due to gout, 77.
Asthma due to gout, 87.
Atonic gout, 4.

B.

Baths for gouty subjects, 135.

Beer-drinking as a cause of gout, 69.

Belladonna, local application of, in acute gout, 141.

Biliary concretions in gouty subjects, 101 ; ducts, gouty inflammation of

the, 99.
Bird, Dr. Golding, on nature of eczematous eruptions in gouty subjects,

94.
Birds and snakes, experiments on, in reference to source of uric acid,

30.

152 INDEX.

Bladder, affections of the, in gouty subjects, 117.

Blood, changes in the, in gout, 8.

Bones, condition of, in gouty subjects. II.

Bright's disease as a result of lithsemia, 108, no.

Bronchitis associated with gout, 87.

Budd, Dr., on gall-stones in gouty subjects, 102 ; on gouty cirrhosis of

the liver, 101.
Buzzard, Dr., on resemblance between gastric symptoms of tabes and

gout in the stomach, 80.

C,

Calculous disorders and gout, 115.

Cantani, Prof., on prevalence of gout in Southern Italy, 59.

Carlsbad waters, value of, for gouty subjects, 133.

Carpenter, Dr., on diet as influencing types of disease, 63.

Cartilages of ears, gouty affections of, 12.

Causes of gout, 58.

Chalk-stones, composition of, 14 ; local treatment of, 144.

Charcot, Prof., on changes in the blood in gout, 8 ; on gouty lesions of

the kidneys, 17 ; on metastasis of gout, 82.
Chevers, Dr. N., on climate of Calcutta as suitable for gouty subjects, 61.
Cirrhosis of the kidney as a result of gout, 18, in ; of the liver due to

gout, 100.
Climate in relation to gout, 60.
Colchicum in the treatment of gout, 141.
Cottle, Mr. W., on connection between eczema and gout, 93.
Cullen's classification of gout, 4 ; views as to nature of gout, 6, 76.
Cutaneous affections connected with gout, 93.
Cystitis connected with gout, 118.

D.
Diabetes, association of, with gout, 118.
Diathesis, meaning of the term, 3 ; symptoms of the uric acid, 45.

INDEX. 15-

Dickinson, Dr., on significance of albuminuria of dyspepsia, 109.

Diet as influencing types of disease, 63.

Diet for gouty subjects, 123, 127.

Diet-rules, importance of, for gouty subjects, 128.

Digestion-albuminuria, 106.

Digestive organs, gouty affections of the, 77.

Duckworth, Dr. Dyce, on neurotic origin of gout, 48.

Dyspepsia, gouty, 77.

E.

Eczema, as a symptom of gouty dyspepsia, 47, 93, 103 ; treatment of,

148.
Errors in diet as a cause of gout, 61.
Exciting causes of gout, 71,
Exercise, necessity of, for gouty subjects, 129.

F.
Farinaceous food, restrictions as to, for gouty subjects, 125.
Frerichs, Prof, on gall-stones in gouty subjects, 102.

G.

Garrod, Dr., method of detecting uric acid in blood-serum, 7 ; on gout
of the heart, 84 ; on place of origin of uric acid, 28 ; on retention
of uric acid in gout, 35 ; on starch and sugar in relation to gout, 64 ;
theory of gout, 6.

Geographical distribution of gout, 59.

Gout, acute, treatment of, 140; affections of the bladder in, 117;
affections of the heart in, 82 ; affections of the kidneys, 15, in ;
affections of the stomach, 79 ; affections of the throat, 79 ; atonic,
regular and retrocedent, 4; caused by lead -poisoning, 70; causes
of, 58 ; chalk-stones in, 14 ; conclusions as to pathology of, 56 ;
condition of urine in acute and chronic forms of, 9 ; Cullen's
classification of, 4; definition of, 4; disorders of liver in, 97;

5 +

INDEX.

geographical distribution of, 59 ; irregular manifestations of, 74 ;
lesions of heart in, 15 ; lesions of kidneys in, 15, in ; meaning of
term, 3; microscopic appearance of deposits in, 13; neurotic
theories of, 48 ; peculiarities of, 1 ; sodium urate in blood in, 7 ;
state of joints in, 1 1 ; theories as to nature, 6 ; visceral, 5, 73 ;
wandering, 5.

Gouty abscesses and ulcers, 14 ; affections of the liver, 98 ; of the nervous
system, 89 ; bronchitis and asthma, 87 ; dyspepsia, albuminuria,
and eczema, 46, 47 ; treatment of, 145 ; kidney, symptoms of,
164 ; treatment of, 146; metastasis, 81 ; phlebitis, 81.

Gravel and gout, relation between, 115.

Graves, Dr., on gouty inflammation of nerves, 92.

Gregory, Dr., case of, proving curability of gout, 121.

Greenhow, Dr. Headlam, on gouty bronchitis, 89.

Guaiacum as a remedy for chronic gout, 143.

H.

Harley, Dr. G., on place of origin of urea, 32.

Headache a frequent symptom in gouty subjects, 91.

Heart, lesions of, in gout, 15 ; retrocedent gout affecting the, 82.

Hepatic alteratives suitable for gouty subjects, 134.

Hepatic congestion, frequency of, in gouty subjects, 98.

Heredity as a cause of gout, 58.

Infarctions in the kidneys due to gout, 16, ill.

Injuries as determining gouty manifestations, 12 ; as exciting causes of

gouty paroxysms, 72.
Iodide of potassium as a remedy for chronic gout, 142.
Irregular gout, 74.
Italy, prevalence of gout in Southern, 59.

INDEX. 155

J-
Jaundice as a symptom of gouty inflammation of the biliary ducts, 99.
Johnson, Dr. G., on albuminuria as a symptom, 106 ; on granular

kidney and the gouty diathesis, no.
Joints, affections of, in gouty subjects, 10.
Jones, Dr. Bence, on acidity of urine and uric acid, 26.

K.

Kidneys, functions of, with regard to uric acid, 28 ; gouty cirrhosis of
the, in ; lesions of, in gouty subjects, 15 ; urate infarctions in the,
16, 112.

L.

Lactic acid fermentation as a cause of acidity, 67.

Latent albuminuria, Dr. G. Johnson on, 106.

Latham, Dr. P. W., on formation of uric acid, 33 ; on nature of gout, 53.

Lead-poisoning as a cause of gout, 70.

Lithaemia, due to functional disorder of the liver, 43 ; symptoms of, 44.

Liveing, Dr. E., on connection between megrim and gout, 91 ; on

nature of gout, 51.
Liver, cirrhosis of the, in gout, 100; congestion of the, in gouty subjects,

98 ; functional disorder of the, as a cause of gout, 44 ; functions of

the, 42 ; temperature of the, 43.
Local treatment of acute gout, 141 ; of chronic gout, 144.
Locomotor ataxy, resemblance between gastric symptoms of, and gout

of the stomach, 80.

M.

Mackenzie, Dr. M., on gouty angina, 77.

Meat diet, restrictions with regard to, for gouty subjects, 124.

Meldon, Dr., on nature of gout, 51.

156 INDEX.

Megrim, frequency of, in gouty subjects, 91.
Mental influence as a cause of gout, 71.
Metastasis, gouty, 81.

Microscopic appearance of gouty deposits, 13.
Milk diet for gouty subjects, 126.

Mineral waters and baths suitable for gouty patients, 135.
Misplaced gout, 76.

Murchison, Dr., on functions of the liver, 42 ; on gouty inflammation of
the biliary ducts, 99 ; on lithaemia as a cause of Bright's disease, 108.

N.
Nervous gout, 90.

Nervous system, gouty affections of the, 89.
Neuralgia due to gout, 91.
Neurotic theories of gout, 48.
Niemeyer, Prof. , on gouty meningitis, 89.

O.

Oleaginous food in relation to gout, 66.

Ord, Dr., on formation of calculi, 116 ; on nature of gout, 52.

P.

Paget, Sir James, on gouty cystitis, 118; on gouty phlebitis, 86; on

relation of gout to nervous system, 52.
Parkes, Dr., on place of origin of uric acid and urea, 32.
Pathology of gout, author's conclusions with regard to, 54.
Phlebitis, gouty, 86.

Physiological albuminuria, question as to, 104.
Piffard, Dr., on connection between eczema and gout, 94.
Psoriasis in relation to gout, 95.
Purgatives suitable for gouty subjects, 132.

INDEX. 157

R.

Relation of uric acid to gout, 36.

Renal disorders connected with gout, 103.

Retrocedent gout, 76.

•

S.

Saccharine and starchy food, as influencing gouty manifestations, 64,

Senator, Prof., on physiological albuminuria, 104.

Sensorial functions, disorders of, in gouty subjects, 93,

Sequelae of gout, 5.

Sodium urate, in the blood of gouty persons, 7 ; in the joints and

tissues, 10.
Stimulants, best kinds of, for gouty subjects with feeble digestion, 125.
Stokes, Dr., on connection between bronchitis and gout, 88.
Stomach, gout of the, 78.
Suppressed gout, 74.

T.

Theories as to nature of gout, 6 ; as to place of origin of uric acid, 28.

Throat, gouty affections of the, 77.

Todd, Dr., on curability of gout, 122 ; on gouty bronchitis, 88 ; on
gouty infarctions in the kidneys, 1 13 ; on nature of gout, 6.

Treatment of an acute attack of gout, 140; of gouty disorders of the
liver and kidneys, 145 ; of gouty eczema, 148 ; of the gouty dia-
thesis, 121.

Trousseau on chronic gouty hepatitis, ico.

Types of disease, influence of diet upon, 63.

Turkish baths for gouty subjects, 139.

U.

Ulcers, gouty, due to chalk-stones, 14.

Uric acid, detection of in blood -serum, 7 ; Dr. Latham on formation

[58 INDEX.

of, 33 ; increased formation of, in gout, 40 ; quantity of, excreted
in acute and chronic gout, 9, 25 ; in health, 22 ; in various dis-
eases, 24 ; relation of acidity of urine to, 26 ; retention of, in
gout, 35.
Urine, condition of the, in gout, 9.

V.

Vichy, waters of, for gouty subjects, 135, 137.
Visceral gout, 5, 73.

' W.

Wine as a cause of gout, 68.

Woakes, Dr., on relation of catarrh to lithaemia, 45,

Z.

Zander, Dr., on mechanical exercises for curative purpcses, 130.

HARRISON AND SONS,

PRINTERS IN ORDINARY TO HER MAJESTY,

ST. MARTIN'S LANE,

April, 1885.

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DR. THEODOR BILLROTH.

Professor of Surgery in Vienna.

fENERAL SURGICAL PATHOLOGY AND THERA-
U PEUTICS. In Fifty-one Lectures. A Text-book for
Students and Physicians. Translated from the Fourth German
Edition with the special permission of the Author, and revised
from the Tenth German Edition, by C. E. Hackley, A.M., M.D.
Copiously illustrated, 8vo, 18s.

G. H. BRANDT, M.D.

i.

ROYAT (LES BAINS) IN AUVERGNE, ITS MIN-
ERAL WATERS AND CLIMATE. With Preface by
Dr. Burney Yeo. With Frontispiece and Map, Second Edit.,
crown 8vo, 2s. 6d.

ii.
LTAMMAM R'IRHA ALGIERS. A Winter Health Re-
■*■■*■ sort and Mineral Water Cure Combined. With Frontis-

piece and Map, crown 8vo, 2s. 6d.

GURDON BUCK, M.D.

CONTRIBUTIONS TO REPARATIVE SURGERY;
^ shewing its application to the Treatment of Deformities,,
produced by Destructive Disease or Injury ; Congenital Defects
from Arrest or Excess of Development ; and Cicatricial Contrac-
tions from Burns. Illustrated by numerous Engravings, large
8vo, gs.

ALFRED H. CARTER, M.D. LOND.

Member of the Royal College of Physicians ; Physician to the Queen's

Hospital, Birmingham; Examiner in Medicine for the

University of Aberdeen, &c.

ELEMENTS OF PRACTICAL MEDICINE. Third
" Edition, crown 8vo, gs. {Just published.

Catalogue of Works

P. CAZEAUX.

Adjunct Professor in the Faculty of Medicine of Paris, &c.

AND

S. TARNIER.

Professor of Obstetrics and Diseases of Women and Children in the Faculty
of Medicine of Paris.

QBSTETRICS; THE THEORY AND PRACTICE;

including the Diseases of Pregnancy and Parturition, Ob-
stetrical Operations, &c. Seventh Edition, edited and revised by
Robert J. Hess, M.D., with twelve full-page plates, five being
coloured, and 165 wood-engravings, 1081 pages, royal 8vo, 35s.

{Now ready.

JOHN COCKLE, MA, M.D.

Physician to the Royal Free Hospital.

AN INTRA-THORACIC CANCER. Svo, 4s 6d.

W. H. CORFIELD, MA, M.D. OXON.

Professor of Hygiene and Public Health in University College, London.

T\ WELLING HOUSES: their Sanitary Construction and
^ Arrangements. Illustrations, Second Edition, crown Svo,
3s. 6d. [Just ready.

EDWARD COTTERELL, M.R.C.S. ENG., L.R.C.P. LOND.

Late House Surgeon, University College Hospital ; Atkinson Morley Surgical
Scholar, University College, London, etc. etc.

AN SOME COMMON INJURIES TO LIMBS: their
^ Treatment and After-Treatment including Bone-Setting (so-
called). Imp. i6mo, with Illustrations. [jf!lst ready.

Late Lecturer on Mental Diseases at Guy's Hospital.

THE SCIENCE AND PRACTICE OF MEDICINE
1 IN RELATION TO MIND, the Pathology of the Nerve
Centres, and the Jurisprudence of Insanity ; being a Course of
Lectures delivered at Guy's Hospital. Illustrated by Chromo-
lithographic Drawings and Physiological Portraits. Svo, 14s.

Published by H. K. Lewis.

HORACE DOBELL, M.D.

Consulting Physician to the Royal Hospital for Diseases of the Chest, &c.

I.
QN DIET AND REGIMEN IN SICKNESS AND
^ HEALTH, and on the Interdependence and Prevention of
Diseases and the Diminution of their Fatality. Seventh edition,
8vo, ios. 6d.

ii.
AFFECTIONS OF THE HEART AND IN ITS
A NEIGHBOURHOOD. Cases, Aphorisms, and Commen-
taries. Illustrated by the heliotype process. 8vo, 6s 6d.

JOHN EAGLE.

Member of the Pharmaceutical Society.

NOTE-BOOK OF SOLUBILITIES. Arranged chiefly
for the use of Prescribers and Dispensers. i2mo, 2s 6d.

JOHN ERIC ERICHSEN.

Holme Professor of Clinical iSurgery in University College ; Senior Surgeon
to University College Hospital, &c.

MODERN SURGERY; ITS PROGRESS AND TEN-
DENCIES. Being the Introductory Address delivered at
University College at the opening of the Session, 1873-74. Demy
8vo, is.

DR. FERBER.

MODEL DIAGRAM OF THE ORGANS IN THE
THORAX AND UPPER PART OF THE ABDOMEN.
With Letter-press Description. In 4to, coloured, 5s.

Catalogue of "Works

AUSTIN FLINT, JR., M.D.

Professor of Physiology and Physiological Anatomy in the Bellevue Medical
College, New York ; Attending Physician to the Bellevue Hospital, &c.

A TEXT-BOOK OF HUMAN PHYSIOLOGY; Designed
"" for the Use of Practitioners and Students of Medicine.
Illustrated by plates, and 313 wood engravings, large 8vo, 28s.

n.
THE PHYSIOLOGY OF THE SPECIAL SENSES
1 AND GENERATION. Being Vol. V. of the Physio-
logy of Man. Roy. 8vo, iSs.

Member of the Royal College of Physicians of London ; Physician to the City
of London Hospital for Diseases of the Chest, Victoria Park, &c.

THE HEART AND ITS DISEASES, WITH THEIR
1 TREATMENT; INCLUDING THE GOUTY HEART.
Second Edition, entirely re-written, copiously illustrated with
woodcuts and lithographic plates. 8vo, 16s.

11.
INDIGESTION, BILIOUSNESS, AND GOUT IN ITS
1 PROTEAN ASPECTS.

Part I.— INDIGESTION AND BILIOUSNESS.

Post 8vo, 7s 6d.
Part II.— GOUT IN ITS PROTEAN ASPECTS.

Post 8vo, 7s. 6'd.

in.
UEART STARVATION. (Reprinted from the Edinburgh
** Medical Journal), 8vo, is.

ERNEST FRANCIS, F.C.S.

Demonstrator of Practical Chemistry, Charing Cross Hospital.

PRACTICAL EXAMPLES IN QUANTITATIVE

* ANALYSIS, forming a Concise Guide to the Analysis of
Water, &c. Illustrated, fcap. 8vo, 2s. 6d.

Published by H. K. Lewis.

HENEAGE GIBBES, M.D.

Lecturer on Physiology and Histology in the Medical School of Westminster
Hospital; late Curator of the Anatomical Museum at King's College.

DRACTICAL HISTOLOGY AND PATHOLOGY.

Second Edition, revised and enlarged. Crown 8vo, 5s.

C. A. GORDON, M.D., C.B.

Deputy Inspector General of Hospitals, Army Medical Department.

"REMARKS ON ARMY SURGEONS AND THEIR
1X WORKS. Demy 8vo, 5s.

W. R. GOWERS, M.D., F.R.C.P., M.R.C.S.

Physician to University College Hospital, &c.

T)IAGRAMS FOR THE RECORD OF PHYSICAL

^ SIGNS. In books of 12 sets of figures, is. Ditto, un-
bound, is.

SAMUEL D. GROSS, M.D.

Professor of Surgery in the Jefferson Medical College of Philadelphia.

A PRACTICAL TREATISE ON THE DISEASES,
A INJURIES, AND MALFORMATIONS OF THE
URINARY BLADDER, THE PROSTATE GLAND, AND
THE URETHRA. Third Edition, revised and edited by S. W.
Gross, A.M., M.D., Surgeon to the Philadelphia Hospital.
Illustrated by 170 engravings, 8vo, 18s.

SAMUEL W. GROSS, A.M., M.D.

Surgeon to, and Lecturer on Clinical Surgery in, the Jefferson Medical College
Hospital, and the Philadelphia Hospital, &c.

A PRACTICAL TREATISE ON TUMOURS OF THE
A MAMMARY GLAND; embracing their Histology, Pa-
thology and Treatment. With Illustrations, 8vo, 10s 6d.

Catalogue of Works

WILLIAM A. HAMMOND, M.D.

Professor of Mental and Nervous Diseases in the Medical Department of the
University of the City of New York.

I.

A TREATISE ON THE DISEASES OF THE NER-

A VOUS SYSTEM. Seventh Edition, with 112 Illustrations,
large 8vo, 25s.

11.
A TREATISE ON INSANITY. Large 8vo, 25s.

in.
CPIRITUALISM AND ALLIED CAUSES AND CON-
u DITIONS OF NERVOUS DERANGEMENT. With
Illustrations, post 8vo, 8s. 6d.

ALEXANDER HARVEY, M.D.

Emeritus Professor of Materia Medica in the University of Aberdeen, &c.

AND

ALEXANDER DYCE DAVIDSON, M.D.

Professor of Materia Medica in the University of Aberdeen.

SYLLABUS OF MATERIA MEDICA FOR THE USE
OF TEACHERS AND STUDENTS. Based on a selec-
tion or definition of subjects in teaching and examining ; and
also on an estimate of the relative values of articles and prepara-
tions in the British Pharmacopoeia with doses affixed. Seventh
Edition, i6mo. [In preparation.

GRAILY HEWITT, M.D.

Professor of Midwifery and Diseases of Women in University College, Obste-
trical Physician to University College Hospital, &c.

UTLINES OF PICTORIAL DIAGNOSIS OF DIS-
EASES OF WOMEN. Folio, 6s.

0

BERKELEY HILL, M.B. LOND., F.R.C.S.

Professor of Clinical Surgery in University College ; Surgeon to University
College Hospital, and to the Lock Hospital.

THE ESSENTIALS OF BANDAGING. For Managing
•* Fractures and Dislocations ; for administering Ether and
Chloroform ; and for using other Surgical Apparatus. Fifth Edi-
tion, revised and much enlarged, with Illustrations, fcap. 8vo, 5s.

Published by H. K. Lewis.

BERKELEY HILL, M.B. LOND., F.R.C.S.

Professor of Clinical Surgery in University College ; Surgeon to University
College Hospital, and to the Lock Hospital.

ARTHUR COOPER, L.R.C.P., M.R.C.S.

Late House Surgeon to the Lock Hospital, &c.

CYPHILIS AND LOCAL CONTAGIOUS DISOR-
^ DERS. Second Edition, entirely re-written, royal 8vo, 18s.

ii.
THE STUDENT'S MANUAL OF VENEREAL DIS-
A EASES. Being a Concise Description of those Affections
and of their Treatment. Third Edition, post 8vo, 2S. 6d.

UINTS TO CANDIDATES FOR COMMISSIONS IN
11 THE PUBLIC MEDICAL SERVICE: with Examin-
ation Questions, Vocabulary of Hindustani Medical Terms, etc.
8vo, 2S.

SIR W. JENNER, BART., M.D.

Physician in Ordinary to H.M. the Queen, and to H.R.H.the Prince of Wales.

THE PRACTICAL MEDICINE OF TO-DAY : Two

A Addresses delivered before the British Medical Association,
and the Epidemiological Society. Small 8vo, is. 6d.

C. M. JESSOP, M.R.C.P.

Associate of King's College, London ; Brigade Surgeon H.M.'s British Forces.

A SIATIC CHOLERA, being a Report on an Outbreak of
■"■ Epidemic Cholera in 1876 at a Camp near Murree in India.
With map, demy 8vo, 2s. 6d.

GEORGE LINDSAY JOHNSON, M.A., M.B., B.C.CANTAB.

Clinical Assistant, late House Surgeon and Chloroformist, Royal Westminster
Ophthalmic Hospital.

A NEW METHOD OF TREATING CHRONIC
■"■ GLAUCOMA : Based on Recent Researches into its

Pathology. With Illustrations and Coloured Frontispiece,

demy 8vo, 3s. 6d.

10 Catalogue of Works

RUSTOMJEE NASERWANJEE KHORY, M.D. BRUX., M.R.C.P.

rFHE PRINCIPLES AND PRACTICE OF MEDI-
■*- CINE. Second Edition, revised and much enlarged, 2
vols., large 8vo, 28s.

NORMAN W. KINGSLEY, M.D.S., D.D.S.

President of the Board of Censors of the State of New York ; Member of the
American Academy of Dental Science, &c.

A TREATISE ON ORAL DEFORMITIES AS A
BRANCH OF MECHANICAL SURGERY. With over
350 Illustrations, 8vo, 16s.

E. A. KIRBY, M.D., M.R.C.S.

Late Physician to the City Dispensary.

A PHARMACOPOEIA OF 'SELECTED REMEDIES
WITH THERAPEUTIC ANNOTATIONS, Notes on
Alimentation in Disease, Air, Massage, Electricity and other
Supplementary Remedial Agents, and a Clinical Index ; arranged
as a Handbook for Prescribers. Sixth Edition, enlarged and re-
vised, demy 4to, 7s.

11.
AN THE VALUE OF PHOSPHORUS AS A REMEDY
u FOR LOSS OF NERVE POWER. Fifth Edition, 8vo,
2s 6d.

J. WICKHAM LEGG, F.R.C.P.

Assistant Physician to Saint Bartholomew's Hospital, and Lecturer on
Pathological Anatomy in the Medical School.

I.
QN THE BILE, JAUNDICE, AND BILIOUS DIS-
u EASES. With Illustrations in chromo-lithography, 710
pages, roy. 8vo, 25s.

11.
A GUIDE TO THE EXAMINATION OF THE
■tt- URINE ; intended chiefly for Clinical Clerks and Stu-
dents. Fifth Edition, revised and enlarged, with additional Illus-
trations, fcap. 8vo, 2s 6d.

in.
A TREATISE ON HEMOPHILIA, SOMETIMES
A CALLED THE HEREDITARY HEMORRHAGIC
DIATHESIS. Fcap. 4to, 7s 6d.

Published by H. K. Lewis. 11

DR. GEORGE LEWIN.

Professor at the Fr. Wilh. University, and Surgeon-in-Chief of the Syphilitic
Wards and Skin Disease Wards of the Charite Hospital, Berlin.

THE TREATMENT OF SYPHILIS WITH SUBCU-
1 TANEOUS SUBLIMATE INJECTIONS. Translated
by Dr. Carl Prcegle, and Dr. E. H. Gale, late Surgeon United
States Army. Small 8vo, 7s.

LEWIS'S PRACTICAL SERIES.

Under this title Mr. Lewis purposes publishing a complete
series of Monographs embracing the various branches of Medicine
and Surgery.

The volumes, written by well-known Hospital Physicians and Surgeons
recognised as authorities in the subjects of which they treat, are in active pre-
paration. The works are intended to be of a thoroughly Practical nature,
calculated to meet the requirements of the general Practitioner, and to present
the most recent information in a compact and readable form ; the volumes
will be handsomely got up, issued at low prices, varying with the size of the
works.

THE FOLLOWING ARE NOW READY.

BODILY DEFORMITIES AND THEIR TREATMENT: A

Handbook of Practical Orthopedics. By H. A. REEVES, F.R.C.S. Ed.,
Senior Assistant Surgeon and Teacher of Practical Surgery at the London
Hospital, Surgeon to the Royal Orthopaedic Hospital, etc. With numer-
ous Illustrations, crown 8vo, 8s. 6d.

DENTAL SURGERY FOR GENERAL PRACTITIONERS

AND STUDENTS OF MEDICINE. By ASHLEY W. BARRETT,
M.B. Lond., M.R.C.S., L.D.S., Dental Surgeon to, and Lecturer on
Dental Surgery and Pathology in the Medical School of, the London
Hospital. With Illustrations, crown 8vo, 3s.

DISEASES OF THE KIDNEY AND MORBID CONDITIONS

OF THE URINE DEPENDENT ON FUNCTIONAL DERANGE-
MENTS. By C. H. RALFE, M.D. Cantab., F.R.C.P. Lond., Assistant
Physician to the London Hospital, late Senior Physician to the Seamen's
Hospital, Greenwich. With Illustrations, crown 8vo. [I» the Press.

*** Prospectus of the Series, with Specimen pages, etc., post free on
application.

} EWIS'S POCKET MEDICAL VOCABULARY.

J-1 [In the press.

12 Catalogue of Works

J. S. LOMBARD, M.D.

Formerly Assistant Professor of Physiology in Harvard College.

I.
EXPERIMENTAL RESEARCHES ON THE RE-
u GIONAL TEMPERATURE OF THE HEAD, under
Conditions of Rest, Intellectual Activity and Emotion. With
Illustrations, 8vo, 8s.

ii.

ON THE NORMAL TEMPERATURE OF THE
HEAD. 8vo, 5s.

WILLIAM THOMPSON LUSK, A.M., M.D.

Professor of Obstetrics and Diseases of Women in the Bellevue Hospital
Medical College, &c.

HPHE SCIENCE AND ART OF MIDWIFERY. Second
A Edition, with numerous Illustrations, 8vo, 18s.

JOHN MACPHERSON, M.D.

Inspector-General of Hospitals H.M. Bengal Army (Retired),
Author of" Cholera in its Home," &c.

ANNALS OF CHOLERA FROM THE EARLIEST
21 PERIODS TO THE YEAR 1817. With a map. Demy
8vo, 7s. 6d.

DR. y. MAGNAN.

Physician to St. Anne Asylum, Paris; Laureate of the Institute.

ON ALCOHOLISM, THE VARIOUS FORMS OF
ALCOHOLIC DELIRIUM AND THEIR TREAT-
MENT. Translated by W. S. Greenfield, M.D., M.R.C.P.
8vo, 7s. 6d.

Published by H. K. Lewis. 13

A. COWLEY MALLEY, B.A., M.B., B.CH. T.C.D.

DHOTO-MICROGRAPHY ; including a description of the
Wet Collodion and Gelatino-Bromide Processes, together
with the best methods of mounting and preparing Microscopic
Objects for Photo-Micrography. Second Edition, with Illustra-
tions and Photographs, crown 8vo, 7s. 6d. [Just published.

PATRICK MANSON, M.D., CM.

Amoy, China.

THE FILARIA SANGUINIS HOMINIS AND CER-
1 TAIN NEW FORMS OF PARASITIC DISEASE IN
INDIA, CHINA, AND WARM COUNTRIES. Illustrated
with Plates, Woodcuts, and Charts. Demy 8vo, 10s. 6d.

PROFESSOR MARTIN.

MARTIN'S ATLAS OF OBSTETRICS AND GYN^-
1T1 COLOGY. Edited by A. Martin, Docent in the University
of Berlin. Translated and edited with additions by Fancourt
Barnes, M.D., M.R.C.P., Physician to the Chelsea Hospital ;
Obstetric Physician to the Great Northern Hospital ; and to
the Royal Maternity Charity of London, &c. Medium 4to,
Morocco half bound, 31s. 6d. net.

J. F. MEIGS, M.D.

Consulting Physician to the Children's Hospital, Philadelphia.

Lecturer on Clinical Medicine ih the University of Pennsylvania.

PRACTICAL TREATISE ON THE DISEASES

OF CHILDREN. Seventh Edition, revised and enlarged
roy. 8vo, 28s.

A

14 Catalogue of Works

WILLIAM MARTINDALE, F.C.S.

Late Examiner of the Pharmaceutical Society, and late Teacher of Pharmacy
and Demonstrator of Materia Medica at University College.

AND

W. WYNN WESTCOTT, M.B. LOND.

Deputy Coroner for Central Middlesex.
"THE EXTRA PHARMACOPOEIA of Unofficial Drugs and
A Chemical and Pharmaceutical Preparations. With References
to their Use abstracted from the Medical Journals, and a Thera-
peutic Index of Diseases and Symptoms. Third Edition, revised
with numerous additions, limp roan, med. 24mo, 7s.

{Now ready.

WM. JULIUS M1CKLE, M.D., M.R.O.P.

Member of the Medico-Psychological Association of Great Britain and Ire-
land ; Member of the Clinical Society, London ; Medical Superintendent,
Grove Hall Asylum, London.

GENERAL PARALYSIS OF THE INSANE. 8vo, 10s.

KENNETH W. MILLICAN, B.A. CANTAB., M.R.0.8.
'HE EVOLUTION OF MORBID GERMS: A Contri-
bution to Transcendental Pathology. Cr. 8vo, 3s. 6d.

T

STEPHEN MONCKTON, M.D., F.R.C.P.
HE METAPHYSICAL ASPECT OF NATURAL
HISTORY. Illustrations, imp. i6mo, 2s.

E. A. MORSHEAD, M.R.C.S., LR.C.P.

Assistant to the Professor of Medicine in University College, London.
•ABLES OF THE PHYSIOLOGICAL ACTION OF
DRUGS. Fcap. 8vo, is.

A. STANFORD MORTON, M.B., F.R.G.S. ED.

Senior Assistant Surgeon, Royal South London Ophthalmic Hospital.
DEFRACTION OF THE EYE: Its Diagnosis, and the
■*■*■ Correction of its Errors, with Chapter on Keratoscopy.
Second Edition. Small 8vo, 2s. 6d.

Published by H. K. Lewis. 15

WILLIAM MURRELL, M.D., F.R.C.P.

Lecturer on Materia Medica and Therapeutics at Westminster Hospital;
Examiner in Materia Medica in the University of Edinburgh.

w

I.
HAT TO DO IN CASES OF POISONING. Fourth
Edition, revised and enlarged, royal 321110, 3s. 6d.

N

11.

ITRO-GLYCERINE AS A REMEDY FOR ANGINA
PECTORIS. Crown 8vo, 3s. 6d.

WILLIAM NEWMAN,

Surgeon to the Stamford Infirmary.

CURGICAL CASES: Mainly from the Wards of the
^ Stamford, Rutland, and General Infirmary. 8vo, paper
boards, 4s. 6d.

DR. FELIX VON N1EMEYER.

Late Professor of Pathology and Therapeutics ; Director of the Medical Clinic
of the University of Tubingen.

A TEXT-BOOK OF PRACTICAL MEDICINE, WITH
PARTICULAR REFERENCE TO PHYSIOLOGY AND
PATHOLOGICAL ANATOMY. Translated5) from the Eighth
German Edition, by special permission of the Author, by George
H. Humphrey, M.D., and Charles E. Hackley, M.D. Revised
Edition, 2 vols., large 8vo, 36s.

C. F. OLDHAM, M.R.C.S., L.R.C.P.

Surgeon H.M, Indian Forces; late in Medical charge of the Dalhousie
Sanitarium.

WHAT IS MALARIA? AND WHY IS IT MOST

vv INTENSE IN HOT CLIMATES? An explanation of
the Nature and Cause of the so-called Marsh Poison, with
the Principles to be observed for the Preservation of Health in
Tropical Climates and Malarious Districts. Demy 8vo, 7s. 6d.

16 Catalogue of Works

G. OLIVER, M.D., M.R.O.P.

i.
THE HARROGATE WATERS: Data Chemical and
Therapeutical, with notes on the Climate of Harrogate.
Addressed to the Medical Profession. Crown 8vo, with Map of
the Wells, 3s. 6d.

11.
QN BEDSIDE URINE TESTING : a Clinical Guide to
^ the Observation of Urine in course of Work. Third Edit.,
considerably enlarged, fcap. 8vo, 3s. [Just published

JOHN S. PARRY, M.D.

Obstetrician to the Philadelphia Hospital, Vice-President of the Obstetrical
and Pathological Societies of Philadelphia, &c.

17XTRA-UTERINE PREGNANCY; Its Causes, Species,
■" Pathological Anatomy, Clinical History, Diagnosis, Prog-
nosis and Treatment. 8vo, 8s.

E. RANDOLPH PEASLEE, M.D., LLD.

Late Professor of Gynaecology in the Medical Department of Dartmouth Col-
lege ; President of the New York Academy of Medicine, &c, &c.

QVARIAN TUMOURS: Their Pathology, Diagnosis, and
^ Treatment, especially by Ovariotomy. Illustrations, roy.
8vo, 16s.

G. V. POORE, M.D., F.R.C.P.

Professor of Medical Jurisprupence, University College ; Assistant Physician

and Physician in charge of the Throat Department of University

College Hospital.

T ECTURES ON THE PHYSICAL EXAMINATION
u OF THE MOUTH AND THROAT. With an appendix
of Cases. 8vo, 3 s. 6d.

R. DOUGLAS POWELL, M.D., F.R.C.P., M.R.C.S.

Physician to the Hospital for Consumption and Diseases of the Chest at
Brompton, Physician to the Middlesex Hospital.

DISEASES OF THE LUNGS AND PLEURA.

*^ Third Edition, re-written and enlarged, with Illustrations,

8vo. [In the press.

C. H. RALFE, M.A., M.D. CANTAB., F.R.C.P. LOND.

Assistant Physician to the London Hospital; late Senior Physician to the
Seamen's Hospital, Greenwich.

DISEASES OF THE KIDNEY AND MORBID
CONDITIONS OF THE URINE DEPENDENT ON
FUNCTIONAL DERANGEMENTS. With Illustrations,
crown 8vo. [In the press.

Published by H. K. Lewis. 17

AMBROSE L RANNEY, A.M., M.D.

Adjunct Professor of Anatomy in the University of New York, &c.

THE APPLIED ANATOMY OF THE NERVOUS

SYSTEM, being a study of this portion of the Human
Body from a stand-point of its general interest and practical
utility, designed for use as a Text-book and a work of Reference.
With 179, Illustrations, 8vo, 20s.

H. A. REEVES, F.R.C.S. ED.

Senior Assistant Surgeon and Teacher of Practical Surgery at the London
Hospital ; Surgeon to the Royal Orthopaedic Hospital, &c.

"DODILY DEFORMITIES AND THEIR TREAT-
U MENT : A Handbook of Practical Orthopedics. With
numerous Illustrations, crown 8vo, 8s. 6d. [Now ready.

Lewis's Practical Series'] .

0

RALPH RICHARDSON, M.A., M.D.

Fellow of the College of Physicians, Edinburgh.

N THE NATURE OF LIFE : An Introductory Chapter
to Pathology. Second Edition, revised and enlarged,

Fcap. 4to, 10s. 6d.

R

W. RICHARDSON, M.A., M.D., M.R.C.P.

EMARKS ON DIABETES, ESPECIALLY IN RE-
FERENCE TO TREATMENT. Demy 8vo, 2s. 6d.

SYDNEY RINGER, M.D.,

Professor of the Principles and Practice of Medicine in University College ;

Physician to, and Professor of Clinical Medicine in, University

College Hospital.

A HANDBOOK OF THERAPEUTICS. Eleventh Edition,
"■ revised, 8vo . [In the press.

11.

ON THE TEMPERATURE OF THE BODY AS A
MEANS OF DIAGNOSIS AND PROGNOSIS IN
PHTHISIS. Second Edition, small 8vo, 2S. 6d.

18 Catalogue of Works

FREDERICK T. ROBERTS, M.D., B.SC, F.R.C.P.

Examiner in Medicine at the Royal College of Surgeons ; Professor of Thera-
peutics in University College ; Physician to University College Hospital ;
Physician to the Brompton Consumption Hospital, &c.

I.

A HANDBOOK OF THE THEORY AND PRACTICE
A OF MEDICINE. Sixth Edition, with Illustrations, in
one volume, large 8vo, 21s. [Just published.

N

11.

OTES ON MATERIA MEDICA AND PHARMACY.

Fcap. 8vo, 7s. 6d. [Now ready.

D. B. ST. JOHN ROOSA, M.A., M.D.

Professor of Diseases of the Eye and Ear in the University of the City of New

York; Surgeon to the Manhattan Eye and Ear Hospital ; Consulting

Surgeon to the Brooklyn Eye and Ear Hospital, &c, &c.

A PRACTICAL TREATISE ON THE DISEASES OF
-"• THE EAR, including the Anatomy of the Organ. Sixth
Edition, Illustrated by wood engravings and chromo-lithographs,
large 8vo, 25s.

W. H. 0. SANKEY, M.D. LOND., F.R.C.P.

Late Lecturer on Mental Diseases, University College, and School of Medi-
cine, London ; Formerly Medical Superintendent (Female Department) of
Hanwell Asylum ; President of Medico-Psychological Society, &c.

T ECTURES ON MENTAL DISEASE. Second Edi-
~ tion, with coloured plates, 8vo, 12s. 6d. [Now ready.

ALDER SMITH, M.B. LOND., F.R.C.S.

Resident Medical Officer, Christ's Hospital, London.

"DINGWORM : ITS DIAGNOSIS AND TREATMENT.
-**• Third Edition, rewritten and enlarged, fcap. 8vo.

[In the press.

Published by H. K. Lewis. 19

J. LEWIS SMITH, M.D.

Physician to the New York Infants' Hospital ; Clinical Lecturer on Diseases
of Children in Bellevue Hospital Medical College.

A TREATISE ON THE DISEASES OF INFANCY

21 AND CHILDHOOD. Fifth Edition, with Illustrations,
(large 8vo, 21s.

FRANCIS W. SMITH, M.B., B.S.

THE LEAMINGTON WATERS: Chemically, Thera-
A peutically, and Clinically Considered ; with Observations

-on the Climate of Leamington. With Illustrations, crown 8vo,
2s. 6d.

JAMES STARTIN, M.B., M.R.C.S.

Surgeon and Joint Lecturer to St. John's Hospital for Diseases of the Skin.

T ECTURES ON THE PARASITIC DISEASES OF
■Lj THE SKIN. Vegetoid and Animal. With Illustrations,
crown 8vo, 3s. 6d.

LEWIS A. STIMSON, B.A., M.D.

Surgeon to the Presbyterian Hospital ; Professor of Pathological Anatomy in
the Medical Faculty of the University of the City of New York.

A MANUAL OF OPERATIVE SURGERY. With

— three hundred and thirty-two Illustrations. Post 8vo,
10s. 6d.

HENRY R. SWANZY, A.M., M.B., F.R.C.S.I.

Examiner in Ophthalmic Surgery University of Dublin; Surgeon to the

National Eye and Ear Infirmary, Dublin ; Ophthalmic Surgeon

to the Adelaide Hospital, Dublin.

HANDBOOK OF DISEASES OF THE EYE AND
THEIR TREATMENT. Illustrated with Wood En-
gravings, Colour Tests, etc., large post 8vo, 10s. 6d. [Now ready.

20 Catalogue of Works

HUGH OWEN THOMAS, M.R.C.S.

DISEASES OF THE HIP, KNEE, AND ANKLE
*^ JOINTS, with their Deformities, treated by a new and effi-
cient method. With an Introduction by Rushton Parker,
F.R.C.S., Lecturer on Surgery at the School of Medicine,
Liverpool. Second Edition, 8vo, 25s.

11.
CONTRIBUTIONS TO MEDICINE AND SURGERY:

Part i. — Intestinal Obstruction ; with an appendix on the Ac-
tion of Remedies. 10s.

,, 2. — The Principles of the Treatment of Joint Disease,
Inflammation, Anchylosis, Reduction of Joint De-
formity, Bone Setting. 5s.

5. — On Fractures of the Lower Jaw. is.

. — The Inhibition of Nerves by Drugs,
hibitory Nerve-Fibres do not exist.

(Parts 3, 4, 6, 7, g, 10, are expected shortly).

8. — The Inhibition of Nerves by Drugs. Proof that In-
hibitory Nerve-Fibres do not exist, is.

J. ASHBURTON THOMPSON, M.R.C.S.

FREE PHOSPHORUS IN MEDICINE WITH SPE-
CIAL REFERENCE TO ITS USE IN NEURALGIA.
A contribution to Materia Medica and Therapeutics. An account
of the History, Pharmaceutical Preparations, Dose, Internal
Administration, and Therapeutic uses of Phosphorus ; with a
Complete Bibliography of this subject, referring to nearly 200
works upon it. Demy 8vo, 7s. 6d.

J. C. THOROWGOOD, M.D.

Assistant Physician to the City of London Hospital for Diseases of the Chest.

THE CLIMATIC TREATMENT OF CONSUMPTION
1 AND CHRONIC LUNG DISEASES, Third Edition,
post 8vo, 3s. 6d.

Published by H. K. Lewis. 21

EDWARD T. TIBBITS, M.D. LOND.

Physician to the Bradford Infirmary and to the Bradford Fever Hospital.

MEDICAL FASHIONS IN THE NINETEENTH
1)1 CENTURY: including a sketch of Bacterio-Mania and
the Battle of the Bacilli. Crown 8vo, 2s. 6d.

LAURENCE TURNBULL, M.D., PH.G.

Aural Surgeon to Jefferson Medical College Hospital, &c, &c.

A RTIFICIAL ANESTHESIA : A Manual of Anesthetic
-**■ Agents, and their Employment in the Treatment of Disease.
Second Edition with Illustrations, crown 8vo, 6s.

|W. H. VAN BUREN, M.D., LLD.

Professor of Surgery in the Bellevue Hospital Medical College.

TVISEASES OF THE RECTUM: and the Surgery of the
■U Lower Bowel. Second Edition, with Illustrations, 8vo,
14s.

RUDOLPH VIRCHOW, M.D.

Professor in the University, and Member of the Academy of Sciences of
Berlin, &c.

TNFECTION-DISEASES IN THE ARMY, chiefly
-1- Wound Fever, Typhoid, Dysentery, and Diphtheria.
Translated from the German by John James, M.B., F.R.C.S.
Fcap. 8vo, is. 6d.

ALFRED VOGEL, M.D.

Professor of Clinical Medicine in the University of Dorpat, Russia.

A PRACTICAL TREATISE ON THE DISEASES
-"- OF CHILDREN. Translated and Edited by H. Raphael,
M.D. From the Fourth German Edition, Illustrated by six
lithographic plates, part coloured, large 8vo, 18s.

22 Catalogue of Works

A. DUNBAR WALKER, M.D., CM.

rTHE PARENTS' MEDICAL NOTE BOOK.
■*■ Oblong post 8vo, cloth, is. 6d.

JOHN R. WARDELL, M.D., F.R.C.P.

Consulting Physician to Tunbridge Wells General Hospital.

CONTRIBUTIONS TO PATHOLOGY AND THE

u PRACTICE OF MEDICINE. Medium 8vo. [In the press.

A. DE WATTEVILLE, M.A., M.D., B.SC, M.R.C.S.

Physician in Charge of the Electro-therapeutical Department of St. Mary's
Hospital.

A PRACTICAL INTRODUCTION TO MEDICAL
-"- ELECTRICITY. Second Edition, re-written and en-
larged, copiously Illustrated, 8vo, gs.

W. SPENCER WATSON, F.R.C.S., M.B.

Surgeon to the Great Northern Hospital ; Surgeon to the Royal South London
Ophthalmic Hospital.

EYEBALL TENSION: its Effects on the Sight and its
Treatment. With Woodcuts, post 8vo, 2s. 6d.

DISEASES OF THE NOSE AND ITS ACCESSORY
CAVITIES. Profusely Illustrated, demy 8vo, 18s.

ON ABSCESS AND TUMOURS OF THE ORBIT.
Post 8vo, 2S. 6d.

FRANCIS WELCH, F.R.C.S.

Surgeon-Major, A.M.D.

ENTERIC FEVER : its Prevalence and Modifications ;.
Etiology ; Pathology and Treatment ; as illustrated by-
Army Data at Home and Abroad. Demy 8vo, 5s. 6d.

Published by H. K. Lewis. 23

DR. F. WINCKEL

Formerly Professor and Director of the Gynaecological Clinic at the Univer-
sity of Rostock.

rpHE PATHOLOGY AND TREATMENT OF CHILD-
■ BED. A Treatise for Physicians and Students. Trans-

lated from the Second German Edition, with many additional
notes by the Author, by J. R. Chadwick, M.D. 8vo, 14s.

EDWARD WOAKES, M.D.

Senior Aural Surgeon and Lecturer on Aural Surgery at the London Hospital;
Senior Surgeon to the Hospital for Diseases of the Throat.

AN DEAFNESS, GIDDINESS, AND NOISES IN
u THE HEAD.

Part I.— POST-NASAL CATARRH, AND DISEASES
OF THE NOSE CAUSING DEAFNESS. With Illus-
trations, crown 8vo, 6s. 6d.

Part II.— ON DEAFNESS, GIDDINESS, AND NOISES
IN THE HEAD. Third Edition, with Illustrations, crown
8vo. \In preparation.

E. T. WILSON, B.M. OXON., F.R.C.P. LOND.

Physician to the Cheltenham General Hospital and Dispensary.

TjISINFECTANTS AND HOW TO USE THEM.
'•*■' In Packets of one doz. price is.

CLINICAL CHARTS FOR TEMPERATURE OBSERVATIONS, ETC.
Arranged by W. Rigden, M.R.C.S. Price 7s. per 100, or
is. per doz.

Each Chart is arranged for four weeks, and is ruled at the back for making
notes of cases ; they are convenient in size, and are suitable both for hospital
and private practice.

24 Periodical Works.

PERIODICAL WORKS PUBLISHED BY H. K. LEWIS.

THE NEW SYDENHAM SOCIETY'S PUBLICATIONS. Annual Sub-
scription, One Guinea.

(Report of the Society, with Complete List of Works and other information,
gratis on application).

THE NEW YORK MEDICAL JOURNAL. A Weekly Review of Medi-
cine. Annual Subscription, One Guinea, post free.

ARCHIVES OF PEDIA TRICS. A Monthly Journal, devoted to the Diseases
of Infants and Children. Annual Subscription, 12s. 6d., post free.

MEDICAL BULLETIN. A Monthly Journal of Medicine and Surgery.
Edited by Dr. J. V. Shoemaker. Annual Subscription, 5s.

THE THERAPEUTIC GAZETTE. A Monthly Journal, devoted to the
Science of Pharmacology, and to the introduction of New Therapeutic
Agents. Edited by Drs. H. C. Wood and R. M. Smith. Annual Sub-
scription, ios., post free.

THE GLASGOW MEDICAL JOURNAL. Published Monthly. Annual
Subscription, 20s., post free. Single numbers, 2s. each.

LIVERPOOL MEDICO-CHIRURGICAL JOURNAL, including the Pro-
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TRANSACTIONS OF THE COLLEGE OF PHYSICIANS OF PHILA-
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%* Mr. Lewis has transactions with the leading publishing
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Arrangements are made in the interests of Authors either for
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or having them reprinted there, as may be most advantageous.

Mr. Lewis's publications can be procured of any bookseller in
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London : Printed by H. K. Lewis, Gower Street, W.C.

u ■■